Sexual Dysfunction, Endocrinopathy, Fertility Problems

2011 - 59 An oligospermic man who takes 25 mg of clomiphene citrate a day will usually have a: A. low serum LH. B. low serum FSH. C. low serum estradiol. D. high serum testosterone. E. high prolactin.

D . Clomiphene citrate is an antiestrogen that blocks the negative feedback of estrogen on the hypothalmus and pituitary. It will raise the serum FSH, LH, and testosterone. Estradiol may also rise because of peripheral conversion of testosterone through the action of aromatase. When used for idiopathic oligospermia, the majority of (but not all) controlled studies show no effect on pregnancy rates. Clomiphene citrate does not affect prolactin levels. Sigman M, Jarow JP: Male infertility, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 19, p 646.

2009 - 11 A 35-year-old man is a heterozygous carrier of the delta-F508 mutation. Prior to testing his wife, his chance of having a child with cystic fibrosis is: A. 1 in 2. B. 1 in 4. C. 1 in 25. D. 1 in 100. E. 1 in 625.

D . Cystic fibrosis is an autosomal recessive disease with a carrier frequency of 1 in 25. Cystic fibrosis mutations may be severe or mild. Accounting for approximately 70% of cystic fibrosis alleles, the delta-F508 genotype is the most common severe mutation, and results from a three base pair deletion in exon 10 of the cystic fibrosis gene. If both alleles carry the severe mutation, offspring will be affected with the systemic and pulmonary form of cystic fibrosis. Without a priori knowledge of his partner's genotype, the probability of offspring with cystic fibrosis born to a heterozygous carrier is 1:25 x 1:4 = 1:100. Claustres M: Molecular pathology of the CFTR locus in male infertility. REPROD BIOMED ONLINE 2005;10:14-41. Jaffee T, Oates RD: Genetic aspects of infertility, in Lipshultz LI, Howards SS (eds): INFERTILITY IN THE MALE, ed 3. St. Louis, Mosby Year-Book Inc, 1997, chap 15, p 293.

2010 - 106 The most common complaint following 16-dot plication for Peyronie's disease is: A. pain with erection. B. decreased penile sensation. C. discomfort in the area of the suture. D. penile shortening. E. narrowing of penile girth.

D . Sixteen-dot plication for correction of Peyronie's disease is a simple and non-extirpative method to straighten the penis. The most common postoperative complaint in a series of 132 patients was penile shortening (41%) followed by suture pain/discomfort (12%), pain with erection (11%), narrowing of the phallus (9%), decreased penile sensation (6%) and hematoma formation (4%). Jordan GH: Peyronie's disease, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 25, p 829. Dean R, Lue T: Penile plication using the 16-dot technique, in Levine L (ed): PEYRONIE'S DISEASE. Totowa, NJ, Humana Press, 2007, pp 149-159.

2010 - 37 In hypogonadal men, the agent which improves the results of nocturnal penile tumescence testing but does not affect erection in response to erotic films is: A. testosterone. B. L-Dopa. C. sildenafil. D. yohimbine. E. bromocriptine.

A . Androgen replacement in hypogonadal men does increase sexual activity and interest. The relationship between androgen replacement and penile erection is not straightforward. When evaluated with nocturnal penile tumescence testing, hypogonadal men demonstrate decreased erectile activity and this abnormality is corrected with testosterone replacement. Laboratory tested erectile responses to erotic films, however, are usually normal in hypogonadal men. These observations are consistent with the conclusion that the major effect of testosterone therapy on sexual function is to enhance libido and not to directly improve penile erection in a sexual setting. None of the other drugs are known to exert these effects. Lue TF, Broderick GA: Evaluation of nonsurgical management of erectile dysfunction and premature ejaculation, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 22, pp 763-764.

2009 - 85 The etiology of PDE5 inhibitor-associated color vision disturbances (chromatopsia) is: A. PDE6 cross reactivity. B. optic nerve ischemia. C. optic nerve vasocongestion. D. sphincter pupillae paralysis. E. retinal venous congestion.

A . Chromatopsia is the loss of color vision (blue halo effect) and is related to cross reactivity with PDE6. Non-arteritic ischemic optic neuropathy (NAION) is associated with PDE5 inhibitor use, but there is no robust evidence supporting causality. This condition is related to ischemia of the optic nerve. PDE5 inhibitors are associated with no alterations in visual acuity or electroretinography. Lue TF, Broderick GA: Evaluation of nonsurgical management of erectile dysfunction and premature ejaculation, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 22, p 774.

2013 - 23 A 56-year-old man has low libido and a normal physical exam. Morning serum testosterone is 365 ng/dl and prolactin is 48 ng/ml (normal < 20 ng/ml). The next step is: A. repeat prolactin assay. B. serum LH assay. C. pituitary MRI scan. D. testosterone replacement. E. bromocriptine.

A . Elevated serum prolactin from a pituitary tumor that causes clinical symptoms such as low libido, infertility and gynecomastia is usually accompanied by a low serum testosterone. A mildly elevated prolactin, especially accompanying a serum testosterone in the normal range, is rarely clinically significant. Because prolactin has high interassay variability, an elevated prolactin should first be verified by repeat testing. With a normal testosterone, LH assay is unhelpful and exogenous testosterone is not indicated. Likewise, a man with mildly elevated prolactin and normal testosterone is unlikely to benefit from bromocriptine, and MRI is unlikely to reveal a clinically significant anatomic pituitary lesion. The most common cause of low libido in a man with a normal physical exam and adequate testosterone is psychological. Sabanegh E, Agarwal A: Male infertility, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 1, chap 21, p 639.

2014 - 17 Three months following a bilateral nerve sparing radical prostatectomy, a 65-year-old man has erectile dysfunction. He has failed oral therapy and wishes not to pursue intracavernosal injection therapy. He attempts intraurethral alprostadil 1000 mcg. The most likely occurrence is: A. inadequate erection. B. penile pain. C. headache. D. hypotension. E. urethral bleeding.

A . Intra-urethral prostaglandin administration is a reasonable alternative to intracavernosal injection therapy. Significant decrease in blood pressure occurs in approximately 2% of men. Penile pain is estimated to occur in 18-33% of men. Only 40% of men will consistently attain an erection adequate for penetration with intra-urethral alprostadil. Urethral bleeding is reported in about 5% of men and headache is rare.

2011 - 34 A 28-year-old man with Kallmann's syndrome is treated with hCG and FSH injections over two years. His serum testosterone and FSH levels are normal. His semen volume is 1.0 ml, sperm count is six million sperm/ml, and sperm motility is 90%. Well-timed sexual intercourse has not resulted in pregnancy for his wife, whose evaluation is normal. The next step is: A. intrauterine insemination. B. color Doppler scrotal ultrasound. C. ICSI. D. transrectal ultrasound. E. testis biopsy.

A . Intrauterine insemination (IUI) is a highly effective treatment for men with normal semen parameters, especially normal sperm motility. IUI involves placing processed sperm via a catheter inserted through the cervix into the uterine cavity. This bypasses cervical mucous and higher numbers of motile sperm will be able to reach the fallopian tubes. Semen volume and sperm production is limited in men with Kallman's syndrome, because prostate, seminal vesicle and testicular size are affected. However, sperm quality tends to be completely normal. In vitro fertilization is not required at this point, and ICSI is unnecessary. Testis biopsy will not be helpful since the patient is not azoospermic. TRUS is useful to evaluate ejaculatory duct obstruction which is usually associated with azoospermia. It is not associated with Kallmann's syndrome. Sigman M, Jarow JP: Male infertility, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 19, pp 635-636, 651.

2014 - 20 A 32-year-old man with infertility has unilateral absence of the vas deferens and 28 ml testes. Semen analysis reveals a volume of 0.5 ml, azoospermia, and pH of 6.4. FSH is 4.9 IU/l. Transrectal ultrasound reveals ipsilateral seminal vesicle agenesis and contralateral seminal vesical hypoplasia. Genetic testing is normal. The next step is: A. renal ultrasonography. B. scrotal exploration with vasography. C. scrotal ultrasound. D. sweat test. E. testis biopsy.

A . Low volume azoospermic acidic semen suggests lack of seminal vesicle contribution to the semen. The differential diagnosis of this finding is: bilateral ejaculatory duct obstruction and congenital bilateral absence of the vas deferens (CBAVD). Transrectal ultrasound can differentiate between the two entities with CBAVD patients having either seminal vesicle agenesis or seminal vesicle hypoplasia. Bilateral ejaculatory ductal obstruction is associated with midline urethral cysts, bilateral seminal vesicle cysts, or the bilateral seminal vesical cysts with dilation of the ejaculatory ducts. CBAVD variants, as in this patient, one vas may be non-palpable while the other is present in the scrotum but absent in the pelvis. All CBAVD patients (including variants) should have genetic testing for cystic fibrosis. Up to 30% of patients will have no identifiable cystic fibrosis mutation. Some of these patients will have unilateral renal agenesis. It is thought that these patients have CBAVD due to mesonephric ductal-ureteral bud abnormalities. Up to 5% of these patients will be found to have renal agenesis, a finding not associated with CBAVD due to cystic fibrosis. It is therefore recommended that patients with CBAVD with a negative genetic test for cystic fibrosis, have a renal ultrasound performed. Scrotal exploration and vasography are not indicated in CBAVD patients, diagnosis is made by physical exam plus transrectal ultrasound for CBAVD variants. Scrotal ultrasound will not help with the diagnosis. The sweat test is not indicated in this patient with normal genetic testing and no clinical symptoms of cystic fibrosis. Testis biopsy to evaluate infertility is not indicated because the patient has CBAVD, normal FSH, and normal-sized testes. Treatment options for infertility in CBAVD patients is ICSI with sperm retrieval by TESE and implantation by IVF. Note in patients with CBAVD negative for cystic fibrosis, offspring may carry the trait and children with unilateral and bilateral renal agenesis have been reported.

2008 - 50 Optimal treatment for an infertile man with a prolactin-secreting pituitary adenoma is: A. cabergoline. B. testosterone. C. prednisone. D. radiation therapy. E. surgical excision.

A . Most patients with prolactin-secreting pituitary adenomas respond well to medical therapy consisting of either bromocriptine or cabergoline, which blocks release of prolactin from the pituitary gland and often causes regression of the tumor. Cabergoline is more frequently used now than bromocriptine because of the lower side effect profile and less frequent dosing schedule. Surgery is reserved for patients who are unable to tolerate medical therapy. Sigman M, Jarow JP: Male infertility, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 19, p 637.

2008 - 85 A 40-year-old man has recent onset of erectile dysfunction. He also has a long-standing history of hypertension and dyslipidemia, treated with an ACE inhibitor and a statin, respectively. He has been using tadalafil for the past month for his erectile dysfunction. He complains of profound lower limb muscle pain. The next step is: A. switch to another PDE5 inhibitor. B. switch anti-hypertensive to a calcium channel blocker. C. check serum creatine kinase level. D. co-administer a NSAID. E. Doppler ultrasound of lower extremity.

A . Myalgia (leg, back, buttock pain) occurs in about 10% of men using tadalafil, due to venous congestion of the large muscle of the body and there is no evidence that it is the result of rhabdomyolysis. Its severity is variable, however it is severe enough in some men that the medication needs to be switched to another PDE5 inhibitor. While, statins can cause rhabdomyolysis, in this patient, his long-standing use of the statin without myalgia and the chronological association between the pain and the commencement of the tadalafil suggest that the latter is to blame. Lue TF, Broderick GA: Evaluation of nonsurgical management of erectile dysfunction and premature ejaculation, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 22, pp 773-778.

2009 - 67 A 28-year old man has a one-year history of erectile dysfunction unresponsive to sildenafil citrate. His baseline erectile rigidity averages 70% with poor sustaining ability. He obtains a 20% erection following the administration of 10 mcg of PGE1. Duplex Doppler penile ultrasound parameters after injection demonstrate peak systolic velocities of 18 cm/s bilaterally. The next step is: A. administer a second dose of intracavernosal PGE1. B. change to vardenafil. C. intracavernosal injection therapy. D. cavernosometry. E. pudendal arteriography.

A . Obtaining accurate information from duplex Doppler ultrasound requires that the patient obtain an erection similar in quality to his best quality spontaneous (non-medication assisted) erection at home. If this is not achieved, the concern is that sympathetic over-activity may result in falsely abnormal erectile hemodynamics. The patient in this case has abnormal peak systolic velocities, however, he failed to obtain a sufficient erection to accurately assess his erectile history. Therefore, he should receive another dose of vasoactive agent intracavernosally. It has been estimated that greater than 50% of men will require more than one dose of intracavernosal vasoactive agent during erectile hemodynamic assessment. Mulhall JP, Abdel-Moneim A, Abobaks R, Goldstein I: Improving the accuracy of vascular testing of the impotent male: Correction of hemodynamic alterations using a vasoactive medication redosing schedule. J UROL 2001;166:923-926.

2014 - 88 A 61-year-old man develops complete erectile dysfunction following radical prostatectomy and has placement of a two-piece inflatable penile prosthesis. Three months after implantation, he complains of decreased penile size and inability to satisfy his partner. Examination demonstrates a functional prosthesis. The best treatment is: A. referral to a sex therapist. B. combination therapy with sildenafil. C. combination therapy with intraurethral alprostadil. D. upsize to a larger two-pieced inflatable prosthesis. E. remove and implant a three-piece inflatable prosthesis.

A . Over 85% of patients and 70% of partners rate satisfaction following placement of penile prosthesis as very high. That being said, there are still patients who have significant problems with establishing intimacy following the diagnosis and treatment of prostate cancer. There are also patients who note significant decrease in penile size following radical prostatectomy. In this patient with no problems noted with his implant, evaluation and treatment by a sex therapist would be the best treatment. Combination therapy with a PDE5 inhibitor or alprostadil can increase glanular engorgement but are not FDA-approved and would not necessarily help with partner issues. There is no need to change out the prosthesis for a different device if it has been properly sized and implanted.

2011 - 43 Compared to primary penile prosthesis insertion, prosthesis revision is associated with an increased risk of: A. infection. B. mechanical failure. C. erosion. D. persistent penile pain. E. hemorrhage.

A . Overall infection rates following initial penile prosthesis insertion range from 1 to 3%. This rate is considerably higher for revision surgery (7-18%). Antibiotic impregnation of prostheses components has reduced the risk of infection. Risk of mechanical failure, erosion, penile pain, and hemorrhage are not higher after repeat prosthesis insertion. Loss of penile size has been associated with delayed reimplantation, and so early replacement has been advocated for patients considering replacement. Montague DK: Prosthetic surgery for erectile dysfunction, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 23, pp 795-796.

2010 - 69 A 45-year-old man with a history of hypertension and significant tobacco use is impotent one year following a crush injury to the pelvis. A penile arteriogram reveals unilateral focal occlusion of the internal pudendal artery. Treatment should be: A. intracavernous vasoactive injections. B. dorsal venous ligation. C. percutaneous angioplasty. D. arterial revascularization. E. penile prosthesis.

A . Percutaneous or surgical revascularization of the internal pudendal arteries is not indicated owing to the patient's age and associated atherosclerotic vascular disease secondary to smoking. There is no indication for venous ligation. Owing to the vascular disease, penile injections may not be successful but should be implemented prior to insertion of a penile prosthesis. Lue TF, Broderick GA: Evaluation of nonsurgical management of erectile dysfunction and premature ejaculation, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 22, pp 779-781.

2013 - 106 Persistent or recurrent difficulty to allow vaginal entry of a penis, finger, or other object, despite the woman's desire to participate is consistent with the diagnosis of: A. vaginismus. B. persistent sexual arousal disorder. C. dyspareunia. D. sexual aversion disorder. E. genital arousal disorder.

A . Sexual dysfunction in women is complicated in that many of the disorders coexist and isolated disorders are uncommon. Definitions frequently change or are not universally agreed upon. In the Revised Definitions for Female Sexual Dysfunction from the Second International Consensus of Sexual Medicine, vaginismus is the persistent difficulty to allow entry of an object into the vagina despite the desire of the woman to participate. Dyspareunia on the other hand is persistent or recurrent pain with attempted penile-vaginal intercourse. Persistent sexual arousal disorder, sexual aversion disorder and objective arousal disorder are not primarily associated with the difficulty to insert an object into the vagina. Genital arousal disorder consists of complaints of impaired genital sexual arousal, which may include minimal vulvar swelling or vaginal lubrication from any type of sexual stimulation and reduced sexual sensations from caressing genitalia. However, subjective sexual excitement still occurs with nongenital sexual stimuli. In persistent sexual arousal disorder, the patient has spontaneous, intrusive, and unwanted genital arousal in the absence of sexual interest and desire. Arousal is unrelieved by orgasms and the feelings of arousal persist for hours or days. Extreme anxiety or disgust at the anticipation of or attempt at any sexual activity is sexual aversion disorder. Moore CK: Female sexual function and dysfunction, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 1, chap 30, p 826.

2013 - 65 A 32-year-old man with infertility has an ejaculate volume of 3 ml, sperm count of 13 million/ml, 50% motility, and an elevated serum FSH. Physical examination reveals bilaterally small testes, normal vasa, and no evidence of a varicocele. His 28-year-old wife has a normal evaluation. The most appropriate next step is: A. intrauterine insemination. B. testicular biopsy. C. in vitro fertilization. D. clomiphene citrate. E. antisperm antibody testing.

A . The couple is infertile due to idiopathic male factor. Testicular biopsy is unlikely to be helpful in a patient with oligospermia. Any intervention used in this setting is considered empirical. The main choice is between attempts to improve the husband's fertility or assisted reproductive techniques to improve the chances of conception without altering sperm quality. It is controversial whether clomiphene citrate is occasionally effective in men with idiopathic oligospermia but it is definitely not effective in an individual with an elevated serum FSH. This leaves either intrauterine insemination (IUI) or in vitro fertilization (IVF). It is most reasonable to start with IUI in this couple since the wife is under 30 and the husband's total motile sperm count is well above 10 million. IVF would be the first therapeutic option if there were a significant female factor or his sperm count were extremely low. The patient's motility is above the reference value for motility and therefore there is no indication for antisperm antibody testing. Demir B, Dilbaz B, Cinar O, et al: Factors affecting pregnancy outcome of intrauterine insemination cycles in couples with favorable female characteristics. J OBSTET GYN 2011;31:420-423. Dorjpurev U, Kuwahara A, Yano Y, et al: Effect of semen characteristics on pregnancy rate following intrauterine insemination. J MED INVEST 2011;58:127-133.

2012 - 77 A 45-year-old man undergoes bilateral end to side vasoepididymostomy. Semen analysis six months later demonstrates azoospermia. The next step is: A. observation. B. measurement of FSH. C. clomiphene citrate therapy. D. TRUS. E. testicular sperm retrieval.

A . The delayed appearance of sperm in the ejaculate of men undergoing vasoepididymostomy (VE) is common. The mean delay in one reported series was six months (range, 3 to 15 months). The ultimate mean sperm count and motility were found to be similar to subjects with sperm present in the initial semen analysis in this study. Therefore, observation would be the best approach in this situation. The epididymal fluid would have been examined for sperm at the time of VE and the procedure only performed if sperm were identified. Determination of the FSH would not be useful since FSH should be normal in patients with obstructive azoospermia. Clomiphene citrate will raise FSH, LH, and testosterone but not correct the obstruction. TRUS is indicated for ejaculatory duct, not epididymal obstruction. Testicular sperm retrieval is not indicated this early after surgery. Practice Committee of the American Society for Reproductive Medicine. Vasectomy Reversal. FERT & STERIL 2008;90:80. Jarow JP, Sigman, M, Buch JP, Oates RD: Delayed appearance of sperm after end-to-side vasoepididymostomy. J UROL 1995;153:1156.

2011 - 8 A 24-year-old man with azoospermia and an ejaculate volume of 0.5 ml has a palpably normal left vas deferens, a nonpalpable right vas deferens, and a normal DRE. Both testes measure 30 ml. The most useful diagnostic study for infertility is: A. TRUS. B. serum testosterone. C. post-ejaculatory urinalysis. D. testicular biopsy. E. seminal fructose.

A . The differential diagnosis for low ejaculate volume azoospermia is vasal agenesis, ejaculatory duct obstruction, and ejaculatory dysfunction. The presence of unilateral vasal agenesis on physical examination strongly suggests the presence of a congenital anomaly with contralateral segmental vasal atresia. TRUS will help differentiate between a potentially treatable ejaculatory duct obstruction and, more likely, absence or hypoplasia of the contralateral seminal vesicle and ampullary vas deferens. Patients with vasal agenesis do not require either a serum FSH or testicular biopsy unless they have testicular atrophy or another historical risk factor. Seminal fructose does not help differentiate between these two disorders; it is absent in both. Kolettis PN, Sandlow JI: Clinical and genetic features of patients with congenital unilateral absence of the vas deferens. UROL 2002;60:1073-1076. Sigman M, Jarow JP: Male infertility, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 19, pp 619-622.

2013 - 29 A 32-year-old man has azoospermia. Y chromosomal microdeletion assay reveals azoospermia factor b (AZFb) and azoospermia factor c (AZFc) deletions. The next step is: A. adoption. B. clomiphene citrate. C. recombinant FSH. D. testis biopsy. E. microsurgical testicular sperm extraction.

A . The long arm of the Y chromosome harbors genes intrinsic to spermatogenesis, including the azoospermia factor (AZF). While males with AZFc deletions may or may not have sperm in the seminiferous epithelium, an AZFa and/or AZFb deletion in combination with an AZFc deletion uniformly results in a Sertoli cell only phenotype. Biopsy is unnecessary, and microsurgical testicular sperm extraction will not yield sperm. Endocrine therapy with clomiphene citrate to stimulate Leydig cell production of testosterone, or with recombinant follicle stimulating hormone to stimulate Sertoli cell function, will not yield sperm as no germ cells are present. Jarow J, Sigman M, Kolettis PN, et al: The optimal evaluation of the infertile male. OPTIMAL EVALUATION OF THE INFERTILE MALE BEST PRACTICE STATEMENT. American Urological Association Education and Research, Inc, 2010, p 24. http://www.auanet.org/content/media/optimalevaluation2010.pdf Sabanegh E, Agarwal A: Male infertility, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 1, chap 21, p 641.

2014 - 37 Three months after placement of a three-piece inflatable penile prosthesis, a patient has persistent penile shaft pain with inflation. Physical examination of the penis and scrotum is normal. The next step is: A. pelvic and scrotal MRI scan. B. cystourethroscopy. C. 500 mg cephalexin BID for 30 days. D. glansplasty. E. revision of reservoir with a lock out valve.

A . This patient complains of pain only when the device is inflated during intercourse which may indicate that the cylinders are too large and are buckling, causing pain. MRI scan with the prosthesis inflated is the best imaging modality to prove the possible size discrepancy and buckling is the next step. If the diagnosis is confirmed, revision of the penile prosthesis with placement of smaller cylinders will usually resolve the problem. Penile infection following prosthetic placement usually has associated physical signs of infection (warmth, tenderness, erythema, etc.) that exist in both the flaccid or erect state. An SST deformity (floppy glans) is usually well-described by a patient and can be confirmed by physical examination. It can be repaired by moving the glans onto the distal portion of the cylinders with a glansplasty. Cystourethroscopy is indicated in the presence of voiding symptoms and/or possible infection of the penile prosthesis to rule out urethral erosion, but is not indicated in patients with pain only on inflation. Revision with a lock-out valve would only be useful in cases of autoinflation.

2014 - 8 A 34-year-old man and his 29-year-old wife have a two year history of infertility. His physical exam is normal. Semen analysis reveals a volume of 2 ml, sperm 23 mil/ml, 2% motility, and 12% normal morphology. Repeat analysis is similar. The next step is: A. sperm viability assay. B. testosterone and FSH levels. C. karyotype and Y chromosome microdeletion testing. D. scrotal ultrasonography. E. testicular sperm extraction.

A . This patient has a less than 5% motility. This raises the prospect of an ultrastructural abnormality in the sperm tails such as primary ciliary dyskinesia. This is characterized by extremely low motility but relatively high sperm viability on a sperm viability assay. Since the sperm concentration is normal, there is no indication for determination of testosterone, FSH, karyotype, or Y chromosome microdeletion testing. Scrotal ultrasonography will not add any useful information. Testicular sperm extraction is indicated for azoospermia. Since this patient has motile sperm in the semen, there is no reason for sperm extraction. Sperm from patients with ciliary dyskinesia may be used for intra-cytoplasmic sperm injection (ICSI), but pregnancy rates are low.

2010 - 59 A 55-year-old man has lower extremity thrombophlebitis and is started on warfarin. Two weeks later, he experiences abdominal pain and has a blood pressure of 84/50 mmHg. His hemoglobin is 13.5 gm/dl and serum potassium 5.8 mEq/l. A CT scan demonstrates bilateral 4 cm adrenal masses. The next step is I.V. fluids and administration of: A. dexamethasone. B. fresh frozen plasma. C. Kayexalate. D. fluorohydrocortisone. E. Vitamin K.

A . This patient has adrenal insufficiency secondary to bilateral adrenal hemorrhage. This can occur in anticoagulated patients, typically during the first three weeks of therapy. The initial therapy should be administration of I.V. fluids and glucocorticoid therapy. Fresh frozen plasma is not acutely indicated with an adequate hemoglobin level. Kayexalate will help lower a high potassium but not the hypotension from adrenal steroid deficiency. Chronic but not acute adrenal insufficiency is treated with fluorohydrocortisone. Vitamin K will help restore clotting factors depleted by warfarin therapy but is not the initial therapy for this patient. Vaughan ED Jr, Blumenfeld JD: Pathophysiology, evaluation, and medical management of adrenal disorders, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 2, chap 53, pp 1843-1845.

2013 - 103 A 68-year-old man with ESRD has been on dialysis for ten years. He has a malleable penile prosthesis and his caregivers notice a firm, black, necrotic lesion on his glans. He has similar lesions on his fingers and toes. The best treatment is: A. observation and support. B. oral antibiotics for six weeks. C. I.V. antibiotics for six weeks. D. biopsy of lesion. E. removal of prosthesis.

A . This patient has metastatic calciphylaxis of the vessels (dry gangrene) in his digits and glans. This is seen in patients with ESRD and is associated with a high mortality rate. Most of these patients will die of their renal disease within six months. The characteristic lesions show microscopic calcification in the arterioles and capillaries which leads to dry necrosis. Antibiotics are not helpful and biopsies can be harmful as these lesions will not heal well due to their poor blood supply. Removal of the prosthesis would only be indicated if there was subsequent erosion or penile infection. This patient should continue with observation, support and wound care as needed. Jacobson HA: Penile calciphylaxis. UROL 2002;60,344. Frehally J: Bone and mineral metabolism in CKD: Clinical manifestations of renal osteodystrophy, in COMPREHENSIVE CLINICAL NEPHROLOGY, ed 3. Philadelphia, Mosby Elsevier, 2007, chap 74, pp 906-909.

2009 - 74 A 39-year-old man with a large left varicocele requests vasectomy reversal four years after vasectomy. At scrotal exploration, he has rare nonmotile sperm in the right vas deferens and an absence of sperm in clear fluid from the left vas deferens. The next step is: A. bilateral vasovasostomy. B. left varicocelectomy and bilateral vasovasostomy. C. right vasovasostomy and left vasoepididymostomy. D. left testis biopsy and intraoperative wet prep evaluation. E. testicular sperm extraction.

A . With sperm in the vas and a patent abdominal vas deferens, right vasovasostomy is indicated. For men with a brief (<10 years) obstructed interval or clear fluid in the vas deferens, the prognosis for return of sperm to the ejaculate is excellent after vasovasostomy alone, despite intravasal azoospermia. Epididymal exploration and intraoperative testis biopsy will not provide material information to affect treatment decisions. Varicocelectomy and vasovasostomy should not be performed simultaneously, as venous outflow from the testis after varicocele repair is dependent primarily on the vasal vessels that are divided during vasectomy or vasovasostomy, and testicular atrophy may result. Lipshultz LI, Thomas AJ Jr, Khera M: Surgical management of male infertility, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 20, p 681.

2013 - 16 A 53-year-old diabetic man sustains a minor proximal crural perforation during primary implantation of a three-piece inflatable penile prosthesis via a penoscrotal approach. The best management is: A. abort the procedure. B. secure exit tubing of the ipsilateral cylinder. C. extend corporotomy for primary repair. D. place a malleable implant. E. direct closure via perineal approach.

B . A common intraoperative complication with penile prosthesis surgery is crural perforation. If this occurs with insertion of an inflatable device with attached tubing, placing a tunica albuginea closure suture on either side of the exit tubing to keep the cylinder in place has worked sufficiently without requiring a more extensive repair. A more significant perforation injury, including damage to the urethra, would require termination of the procedure. Placement of a malleable prosthesis is not advised as it cannot be secured and will be more likely to erode.

2008 - 132 A 32-year-old man desires a biological child. Both testes are 4 cm in long axis and soft. Two semen analyses reveal azoospermia with volumes 3.0 ml and 3.1 ml. Testosterone is 280 ng/dl (normal 300-1000 ng/dl), LH is 7.5 IU/l (normal 2-12 IU/l) and FSH is 8.5 IU/l (normal 2-12 IU/l). The next step is: A. repeat semen analysis. B. clomiphene citrate. C. hCG and recombinant FSH. D. testis biopsy. E. epididymovasostomy.

B . A testis biopsy is not required to establish the diagnosis of spermatogenic dysfunction, as the likelihood of non-obstructive azoospermia in a man with testis longitudinal axis less than 4.6 cm and FSH greater than 7.6 IU/l is 89%. In a recent multicenter trial, over 60% of men with non-obstructive azoospermia demonstrated sperm in their semen analyses after clomiphene citrate administered with mean duration five months. The clomiphene dose should be titrated to increase the serum testosterone levels to 600-800 ng/dl. A third semen analysis is unlikely to aid in the diagnosis, and with LH and FSH levels in the normal range, exogenous hCG and recombinant FSH are unhelpful. Microsurgical reconstruction will not result in ejaculated sperm because non-obstructive azoospermia is caused by impaired spermatogenesis. Hussein A, Ozgok Y, Ross L, Niederberger C: Clomiphene administration for cases of nonobstructive azoospermia: a multicenter study. J ANDROL 2005;26:787-791. Schoor RA, Elhanbly S, Niederberger CS, Ross LS: The role of testicular biopsy in the modern management of male infertility. J UROL 2002;167:197-200.

2009 - 50 A 38-year-old obese man desires a biological child. Semen analysis shows a volume of 2.0 ml, 5.2 million sperm/ml and 40% motility. Serum testosterone is 312 ng/dl (normal 300 - 1000 ng/dl) and estradiol is 68 pg/ml (normal < 50 pg/ml). The next step is administration of: A. estrogen. B. anastrazole. C. cabergoline. D. testosterone. E. clomiphene citrate.

B . A testosterone:estradiol ratio of less than 5:1 in a male is strongly suggestive of aromatase dysfunction, and is treated with aromatase inhibition including anastrazole 1 mg p.o. daily or 50 to 100 mg testolactone twice daily. Clomiphene citrate would increase both testosterone and estradiol but the ratio would remain unchanged. Cabergoline is a prolactin inhibitor, and exogenous testosterone would suppress spermatogenesis. Raman JD, Schlegel PN: Aromatase inhibitors for male infertility. J UROL 2002;167(2 Pt 1):624-629.

2010 - 142 A 34-year-old man has azoospermia with a seminal volume of 2 ml and pH of 8.3. Physical exam shows small soft testicles each with a normal vas and epididymis. FSH is elevated to 3.5 times normal. The next step is: A. semen fructose determination. B. karyotype and Y chromosome microdeletion assay. C. fine needle testicular aspiration. D. scrotal exploration with testis biopsy and vasography. E. testicular microdissection and cryopreservation of sperm.

B . Azoospermic men have an increased incidence of chromosomal abnormalities. Patients thought to have non-obstructive azoospermia should have both a karyotype and Y-chromosome microdeletion analysis. Of the three types of Y chromosome deletions, types a and b rarely if ever have sperm production in the testicles. Type c deletions have patchy sperm production in the testicles some of the time. The latter may benefit from testicular sperm retrieval but the types a and b deletions will likely not. With an FSH three times normal this patient will not have obstructive azoospermia and thus scrotal exploration and a vasogram are not indicated. Fine needle testicular aspiration for diagnosis is unnecessary. Both needle aspiration and testicular microdissection and cryopreservation of sperm are premature without prior genetic testing. In addition needle aspiration is less successful in retrieving sperm from non-obstructed azoospermic patients than open testicular sperm extraction. Semen fructose determination may demonstrate a low fructose concentration in patients with ejaculatory duct obstruction or congenital bilateral absence of the vas deferens. Both of these conditions are associated with low volume acidic semen specimens which are not present in this patient. Jarow J, Sharlip ID, Belker AM, et al: Report on optimal evaluation of the infertile male: An AUA best practice policy and ASRM Practice Committee report. EVALUATION OF THE INFERTILE MALE BEST PRACTICE STATEMENT. American Urological Association Education and Research, Inc, 2001, p 9. http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines/main-reports/optimalevaluation.pdf

2014 - 65 The primary effect of parathyroid hormone (PTH) is to facilitate: A. 1,25-dihydroxyvitamin D3 activity on the enteric epithelium. B. calcium reabsorption in the renal tubule. C. enzymatic activity of 25-hydroxylase. D. conversion of 7-dehydroxycholesterol to Vitamin D3 (cholecalciferol). E. 1,25-dihydroxyvitamin D3 activity on the renal tubule.

B . Calcium homeostasis involves four key components: serum calcium, serum phosphate (binds calcium thereby blocking calcium bioavailability), 1,25-dihydroxyvitamin D3, and parathyroid hormone (PTH). The major target organs for PTH action are the kidneys, skeletal system, and intestine. The primary effect of PTH is in the kidney, where it will act to block phosphate reabsorption in the proximal tubule (i.e., increase phosphate excretion) and promote calcium reabsorption in the ascending loop of Henle, distal tubule, and collecting tubule. PTH promotes bone resorption with subsequent calcium release. The final function of parathyroid hormone (PTH) is by activation of the enzyme 1-hydroxylase in the proximal tubules of the kidney. The enzyme 1-hydroxylase is a key component in the metabolism of vitamin D3 (cholecalciferol). Vitamin D3 (cholecalciferol) is formed in the skin when a cholesterol precursor, 7-dehydroxycholesterol, is exposed to ultraviolet light. Activation of vitamin D3 occurs when the substance undergoes 25-hydroxylation in the liver and 1-hydroxylation in the kidney. The enzyme 1-hydroxylase converts 25-hydroxyvitamin D3 to its most active metabolite, 1,25-dihydroxyvitamin D3. The primary action of 1,25-dihydroxyvitamin D3 is to promote gut absorption of calcium by stimulating formation of calcium-binding protein within the intestinal epithelial cells.

2012 - 88 A 65-year-old man has been using 20 mg of tadalafil (Cialis) as needed for treatment of erectile dysfunction. His primary care provider starts him on doxazosin for hypertension. His treatment of erectile dysfunction should include: A. continue tadalafil 20 mg as needed. B. decrease tadalafil to 10 mg as needed. C. start tadalafil for once daily use at 5 mg/day. D. stop tadalafil. E. switch to intracorporal alprostadil.

B . Concomitant use of alpha-blockers and PDE-5 inhibitors can cause hypotension. When tadalafil is coadministered with an alpha-blocker, patients should be stable on alpha-blocker therapy prior to initiating treatment with tadalafil, and tadalafil should be initiated at the lowest recommended dose. Conversely, when starting an alpha-blocker the lowest dose of either agent should be used and they should not be taken at the same time. There is no need to stop tadalafil in this patient or switch to intracorporal injections if he has been successful on oral therapy. Of all the choices, decreasing to the lowest effective dose of tadalafil (10 mg for use as needed, or 2.5 mg/day for once daily use) would be recommended for this man. Lue TF, Broderick GA: Evaluation of nonsurgical management of erectile dysfunction and premature ejaculation, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 22, pp 773-777.

2008 - 20 A 32-year-old infertile man with hyperthyroidism has two semen analyses with volumes of 2.2 and 2.5 ml, densities of 5.3 and 7.8 million/ml, and motilities of 48% and 56%, respectively. Serum testosterone is 280 ng/dl (normal 300-1000 ng/dl). Estradiol, LH, FSH, and prolactin are normal. The next step is: A. repeat semen analysis with post-ejaculatory urinalysis. B. serum albumin and sex hormone binding globulin. C. TRUS. D. clomiphene citrate 25 mg daily. E. hCG 5000 units twice weekly.

B . Conditions that increase sex hormone binding globulin levels include anorexia, hyperthyroidism, and cirrhosis. Men with these diseases may have normal bioavailable testosterone with decreased total testosterone. Common clinically available assays for free testosterone are inaccurate, and in the absence of an equilibrium dialysis assay for free testosterone, bioavailable testosterone is best calculated from serum albumin. The semen analyses reveal normal volumes, near normal motilities and low sperm densities. With normal volumes, retrograde ejaculation and ejaculatory ductal obstruction are unlikely, and post-ejaculatory urinalysis and TRUS are not indicated. While both clomiphene citrate and hCG will increase serum testosterone levels, clomiphene citrate is the best initial therapy due to the cost of hCG administration. Prior to therapy, accurate assessment of bioavailable testosterone is necessary in a patient with comorbidities that may alter sex horomone binding globulin. Sokol RZ, Swerdloff RS: Endocrine evaluation, in Lipshultz LI, Howards SS (eds): INFERTILITY IN THE MALE, ed 3. St. Louis, Mosby Year-Book Inc, 1997, chap 11, p 211.

2010 - 71 The enzyme deficiency that most commonly leads to genital ambiguity in a 46 XX individual with normal ovaries is: A. 20,22-desmolase. B. 17-hydroxylase. C. 21-hydroxylase. D. 3B-hydroxysteroid dehydrogenase. E. 17B-hydroxysteroid dehydrogenase.

C . A deficiency of 20,22-desmolase, 3B-hydroxysteroid dehydrogenase and 17-hydroxylase enzymes occur with congenital adrenal hyperplasia but rarely cause genital ambiguity in a 46 XX female. 17B-hydroxysteroid dehydrogenase is primarily a testicular enzyme. A 21-hydroxylase deficiency will cause CAH in both sexes but in a 46 XX individual with ovaries it will lead to genital ambiguity. Only enzyme defects beyond the 17-hydroxyprogestone stage of steroid biosynthesis will produce excessive androgenic substances. Diamond DA: Sexual differentiation: Normal and abnormal, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 128, pp 3816-3821.

2008 - 76 Seminal emission depends on an intact: A. parasympathetic and somatic nervous system. B. sympathetic nervous system. C. parasympathetic nervous system. D. sympathetic and parasympathetic nervous system. E. sympathetic and somatic nervous systems.

B . Emission is defined as the deposition of seminal fluid into the posterior urethra by the vasa deferentia and the seminal vesicles. Ejaculation is the forceful expulsion of seminal fluid out the urethral meatus by contraction of the bulbospongiosus and ischiocavernosus muscles. Since the vasa and the seminal vesicles are innervated primarily by the sympathetic nervous system, emission is under control of the sympathetic nervous system. Alpha-adrenergic nerve stimulation causes not only contraction of the seminal vesicles and vasa deferentia but also closure of the bladder neck. Ejaculation is the result of somatic nerve stimulation of the periurethral striated musculature. The parasympathetic nervous system is not directly involved with either emission or ejaculation. Sheinfeld J, Bartsch G, Bosl GJ: Surgery of testicular tumors, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 30, p 640.

2010 - 66 A 50-year-old man who is receiving exogenous testosterone for treatment of erectile dysfunction will have: A. decreased semen volume. B. decreased sperm count. C. increased FSH. D. increased LH. E. increased prolactin.

B . Exogenous testosterone will suppress pituitary production of LH and FSH. Prolactin levels will be unaffected. Semen volume, which is dependent on circulating testosterone levels, should be unchanged or increased. However, intratesticular levels of testosterone will decrease, resulting in lower sperm production and decreased sperm concentration. Lue TF, Broderick GA: Evaluation of nonsurgical management of erectile dysfunction and premature ejaculation, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 22, p 773.

2013 - 148 The indication for sperm viability testing is: A. sperm density < 5 million sperm per ml. B. sperm motility < 5%. C. Kallmann syndrome. D. Klinefelter syndrome. E. presence of anti-sperm antibodies.

B . Flagellar defects result in motilities of less than 5% - 10%. In these samples most of the non-motile sperm are viable. Most cases of ultrastructural flagellar defects are associated with normal sperm densities. Kallmann syndrome is associated with hypogonadotropic hypogonadism and resultant azoospermia not motility defects. Klinefelter syndrome is associated with azoospermia, not motility defects. Antisperm antibodies may result in low motility but the non-motile sperm are non-viable. Chemes HE, Rawe VY: Sperm pathology: A step beyond descriptive morphology. Origin, characterization and fertility potential of abnormal sperm phenotypes in infertile men. HUMAN REPRODUCTION UPDATE, 2003 vol 9, pp 405-428. Sabanegh E, Agarwal A: Male infertility, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 1, chap 21, p 622.

2008 - 35 A 36-year-old man on chronic hemodialysis has gynecomastia, diminished libido, erectile dysfunction, and bone pain. The primary etiology is: A. reduced sex hormone binding globulin. B. high prolactin. C. low cortisol. D. hyperparathyroidism. E. elevated estradiol.

B . Hyperprolactinemia is a common result of hemodialysis. Physical signs of this condition include diminished libido, erectile dysfunction, infertility and gynecomastia. Treatment with cabergoline or bromocriptine reverses the osteoporosis and low testosterone improving libido and erectile dysfunction. Patel MP, Carson CC: Epidemiology, anatomy, physiology and treatment of erectile dysfunction in chronic renal failure patients. ADV REN REPLACE THER 1999;6:296-309. Sigman M, Jarow JP: Male infertility, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 19, p 637.

2011 - 71 Inhibin is a substance derived from the testicle which mediates secretion of: A. testosterone. B. FSH. C. LH. D. GnRH. E. M|uulm|ccllerian inhibiting factor.

B . Inhibin is a heterodimeric protein hormone in the transforming growth factor family of protein hormones including activin. Inhibin is secreted by the Sertoli cell for normal feedback inhibition of FSH. Testosterone is regulated by LH. Secretion of both FSH and LH is stimulated by gonadotropin-releasing hormone from the hypothalamus. M|uulm|cllerian inhibiting factor is secreted by Sertoli cells during embryogenesis and inhibits the development of the M|uulm|llerian structures. Schlegel PN, Hardy MP, Goldstein M: Male reproductive physiology, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 18, pp 577-578.

2009 - 88 A 32-year-old single man with decreased libido and erectile dysfunction has a serum testosterone of 100 ng/dl (normal 300-1000 ng/dl) and a prolactin of 150 ng/ml (normal 0-15 ng/ml). He has no visual field abnormalities, but an MRI scan demonstrates a 1 cm pituitary tumor. After three months of bromocriptine, his testosterone is 120 ng/dl, and he is still impotent despite normalization of his prolactin and a slight reduction in the size of the tumor. The most appropriate treatment is: A. increase bromocriptine. B. testosterone supplementation. C. transsphenoidal pituitary surgery. D. pituitary radiation. E. hCG.

B . Many men with pituitary macroadenomas require testosterone replacement in addition to bromocriptine. The prolactin secreting tumor lowers LH secretion, probably by destruction of the pituitary cells that make LH. Higher doses of bromocriptine are not indicated if the prolactin is normal. Transsphenoidal surgery or pituitary radiation are not indicated if bromocriptine controls the tumor. Human chorionic gonadotropin would be an appropriate option if the patient was interested in fertility. However, in a single man whose chief complaint is impotence, testosterone replacement is easier to administer and less costly. McVary KT: Erectile dysfunction, in Braunwald E, Fauci AS, Kasper DL, et al (eds): HARRISON'S PRINCIPLES OF INTERNAL MEDICINE, ed 15. New York, McGraw-Hill, 2001, chap 51, p 191.

2014 - 49 A 53-year-old man complains of four months of pain with erections, poor tumescence, and a 30 degree dorsal penile curvature. Physical examination reveals a 1 cm dorsal plaque. The next step is: A. reassurance and observation. B. treatment with sildenafil. C. intracavernous injection therapy. D. tunical plication. E. plaque excision and grafting.

B . Many think that the clinical incidence of Peyronie's disease is increasing. The increase however may be associated and coincide with the increased use of erection-enhancing medications. Phosphodiesterase type 5 (PDE5) inhibitor medications are not contraindicated in the treatment of Peyronie's disease, while intracavernous injection therapy has been linked to the development of penile fibrosis. There has never been any suggestion that PDE5 inhibitors are in any way directly causally related to the development of Peyronie's disease, nor is there suggestion that their use would worsen the course of Peyronie's disease. Data is emerging to suggest that certain endothelial impairment may be reversed with the initiation of PDE5 inhibitor therapy. This patient has erectile dysfunction (ED) and it is reasonable to treat the ED with sildenafil. Reassurance will not improve his ED and surgical correction is not indicated early in the disease course.

2009 - 73 After a radical prostatectomy, a man complains of bothersome penile pain following orgasm. The next step is: A. cystoscopy. B. tamsulosin. C. cyclobenzaprine. D. diazepam. E. gabapentin.

B . Orgasmic pain or dysorgasmia occurs in a distinct minority of men after radical prostatectomy. This pain is located in the penis, testicles, perineum or abdomen and while usually of nuisance level, it can be incapacitating leading to avoidance of sexual relations. This pain may also occur after prostate radiation and in chronic pelvic pain syndromes. The condition is believed to result from bladder neck spasm. It is responsive to uroselective alpha-blockers. Cyclobenzaprine and diazepam are skeletal muscle relaxants. There is no role for gabapentin or cystoscopy in these patients. Barnas J, Parker M, Guhring P, Mulhall JP: The utility of tamsulosin in the management of orgasm-associated pain: A pilot analysis. EUR UROL 2005;47:361-365. Nickel JC, Narayan P, McKay J, Doyle C: Treatment of chronic prostatitis/chronic pelvic pain syndrome with tamsulosin: a randomized double blind trial. J UROL 2004;171:1594-1597.

2014 - 85 A 64-year-old man with erectile dysfunction and a history of coronary disease is taking tadalafil 5 mg daily. During sexual activity, he develops angina. The next step is: A. stop sexual activity and rest. B. stop sexual activity and seek emergency treatment. C. take nitroglycerin only if it has been at least 24 hours since his last tadalafil dose. D. take nitroglycerin only if it has been at least 48 hours since his last tadalafil dose. E. take nitroglycerin only in a medically monitored setting.

B . Patients who are taking PDE5 inhibitors cannot concomitantly use nitrates due to the potential risk of severe hypotension. For the short acting PDE5 inhibitors (vardenafil, sildenafil, avanafil), medical personnel should not use nitrates for at least 24 hours and for 48 hours with the long acting PDE5 inhibitor, tadalafil. Men who have taken PDE5 inhibitors and develop angina during sexual activity (which has a greater risk of bringing on a non-fatal MI) should stop sexual activity and seek emergency medical therapy immediately.

2011 - 53 Primary hyperaldosteronism caused by bilateral adrenal hyperplasia is best managed by: A. salt restriction. B. spironolactone administration. C. captopril administration. D. unilateral adrenalectomy of the larger adrenal. E. bilateral adrenalectomy.

B . Patients with bilateral adrenal hyperplasia are best treated medically. Bilateral adrenalectomy will sacrifice glucocorticoid and mineralocorticoid function. Moreover, either partial or unilateral adrenalectomy will not correct the hypertension accompanying this disorder. While patients become hypokalemic with hyperaldosteronism, neither potassium supplementation nor salt restriction will correct the etiology of the hypertension. Captopril may be indicated in a subset of primary hyperaldosteronism patients in whom aldosterone production is not completely autonomous from angiotensin II stimulation. Vaughan ED Jr, Blumenfeld JD: Pathophysiology, evaluation, and medical management of adrenal disorders, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 2, chap 53, p 1856.

2014 - 52 During placement of a two-piece inflatable penile prosthesis, the glans penis is noted to have poor support and minimal movement over the top of the prosthetic with a mild SST deformity. The best treatment is: A. observation and cycling. B. glansplasty. C. placement of an additional 1 cm rear tip extender. D. upsize the prosthesis. E. convert to a three-piece inflatable prosthesis.

B . Poor support of the glans penis by cylinder or rod tips leads to a drooping appearance of the glans, in which it appears to flop over the prosthesis. This deformity may result from inadequate distal dilation, too short cylinders, or in the case of minor deformity, variations in anatomy where the corpora cavernosum does not extend completely under the glans. For a severe deformity, definitive correction involves removing both cylinders, perforating the distal corpora with scissors, resizing, and then inserting longer cylinders or the same cylinders with longer rear tip extenders. For mild defects, like in this patient, dorsal plication of the glans back onto the shaft of the penis (glansplasty) is preferable when there are minor but otherwise bothersome degrees of poor glanular support. Changing to a three-piece prosthesis is not needed and adding a larger cylinder (upsizing) could result in pain and buckling.

2008 - 55 A 25-year-old single man complains of premature ejaculation, with an intravaginal ejaculatory latency time of 30 seconds. He is distressed by this problem. His penile vibration stimulation thresholds are normal. The next step is: A. psychological counseling. B. daily fluoxetine. C. on demand sertraline. D. daily bupropion. E. topical lidocaine/prilocaine.

B . The patient is bothered by his symptoms and the very short intravaginal ejaculatory latency time suggests that the patient warrants treatment. The local anesthetic of choice is lidocaine/prilocaine. The absence of a regular partner likely renders sex therapy ineffective. The first line pharmacologic treatment of premature ejaculation is selective serotonin reuptake inhibitors (SSRI). Bupropion is not an SSRI. The use of SSRI is best commenced with daily use and it appears that fluoxetine, sertraline and paroxetine are of approximately similar efficacies. While there is not much literature on on-demand use of SSRI it is generally believed that the daily dosing is more effective. Montague DK, Jarow J, Broderick GA, et al: AUA guidelines on the pharmacologic management of premature ejaculation. J UROL 2004;172:290-294.

2012 - 7 A 27-year-old man states that since a radical orchiectomy for stage A seminoma six months previously, the frequency and quality of his erections have been poor. He received XRT to periaortic nodes. The last treatment was two months after the orchiectomy. His chest x-ray, serum markers, glucose, and testosterone are normal. The next step is: A. intracavernosal injection therapy. B. sexual dysfunction counseling. C. intraurethral alprostadil. D. nocturnal penile tumescence studies. E. testosterone patch.

B . The patient should be told that during the early months after surgery, depression and loss of vigor are common along with an impaired sense of body image and mood disturbances. Patients cured of testis cancer rarely have persistent emotional disturbances. Sexual drive does not appear to be permanently disrupted by curative therapy. Treatments such as testosterone should be avoided. With time and reassurance, he should recover his normal libido and potency. Concomitant use of PDE5 inhibitors may also be helpful to reestablish confidence. Reassessment of such patients one year after treatment has shown that depression and mood disturbances have usually cleared. Lue TF: Physiology of penile erection and pathophysiology of erectile dysfunction, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 21, p 742.

2013 - 64 The metabolism of sildenafil may be inhibited by: A. a fatty meal. B. rifampin. C. ritonavir. D. warfarin. E. doxazosin.

C . High fat meals can inhibit the absorption of sildenafil and vardenafil but do not affect the absorption of tadalafil or the metabolism of PDE5 inhibitors. Ketoconazole, itraconazole, and protease inhibitors such as ritonavir can impair the metabolic breakdown of PDE5 inhibitors by blocking the CYP3A4 pathway. These agents may increase blood levels of inhibitors, requiring a PDE5 dose reduction. Agents such as rifampin may induce CYP3A4, enhancing the breakdown of inhibitors and requiring higher PDE5 doses. Warfarin and doxazosin have no effect on the metabolism of PED5 inhibitors. Doxazosin may exacerbate hypotensive changes with PED5 inhibitors. Lue TF, Broderick GA: Evaluation of nonsurgical management of erectile dysfunction and premature ejaculation, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 1, chap 22, p 750. Burnett AL: Evaluation and management of erectile dysfunction, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 1, chap 24, p 742.

2012 - 118 In a man with azoospermia and elevated FSH, the best predictor of sperm retrieval from the testicle is: A. serum FSH level. B. testosterone level. C. Y chromosome deletion subtype. D. seminal volume. E. presence of the vas deferens.

C . In men with azoospermia, 7% will be associated with Y chromosome microdeletions. Classically, these patients will be found to have azoospermia or severe oligospermia with an elevation in FSH. The microdeletions occur in the long arm of the Y chromosome and are designated as AZFa (proximal), AZFb middle, and AZFc distal. The most common deletion is AZFc. About 75% of men with AZFc deletions have sperm on testicular biopsy. Sperm retrieval from men with complete AZFa or AZFb deletions have not been successful. The success of testicular sperm retrieval has not been correlated with FSH or testosterone level. Seminal volume does not reflect spermatogenic potential and has no relationship to the success of sperm retrieval. The absence of the vas deferens may be associated with obstructive azoospermia but these patients should have a normal FSH whereas this patient has an elevated FSH indicating non-obstructive azoospermia. Hopps CV, Mielnik A, Goldstein M, et al: Detection of sperm in men with Y chromosome microdeletions of the AZFa, AZFb and AZFc regions. HUM REPROD 2003;18:1660-1665.

2008 - 88 A 60-year-old man with retinitis pigmentosa and erectile dysfunction fails to get an erection with intracorporal and intraurethral PGE-1. His serum testosterone level is 400 ng/dl and color Doppler peak flow velocity of the cavernous arteries is 16 cm/sec after 20 mcg of PGE-1. The next step is: A. counseling. B. sildenafil. C. insertion of penile prosthesis. D. testosterone supplementation. E. yohimbine.

C . In patients with inherited retinal disorders such as retinitis pigmentosa, sildenafil use is contraindicated. Sildenafil inhibits PDE-VI expression in the retina and exacerbates visual disturbances. Testosterone supplementation is only indicated in the presence of documented hypogonadism. Yohimbine is not a useful treatment. In the presence of documented arterial insufficiency, a penile prosthesis is the best treatment. Lue TF, Broderick GA: Evaluation of nonsurgical management of erectile dysfunction and premature ejaculation, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 22, p 777.

2012 - 94 A 66-year-old man had a radical prostatectomy six years ago for localized prostate cancer. He has had no evidence of recurrence and an undetectable PSA. He now has loss of libido, declining muscle mass, lethargy, and erectile dysfunction. His serum testosterone is 160 ng/dl, and his LH and prolactin levels are normal. The next step is: A. explain that testosterone is contraindicated. B. delay testosterone treatment until he is disease free for ten years. C. start testosterone after a thorough discussion. D. start yohimbine. E. start PDE5 inhibitor.

C . Men successfully treated for prostate cancer and suffering from symptomatic hypogonadism may become candidates for androgen therapy, if there is no evidence of residual cancer after a prudent interval. The risks and benefits must be clearly understood by the patient. Close follow-up is required. Phosphodiesterase inhibitors may be used for first-line therapy of erectile dysfunction, but do not adequately address systemic manifestations of hypogonadism. In hypogonadal men, combined treatment has been reported. Yohimbine is not recommended for the treatment of erectile dysfunction. Morales A, Morley J, Heaton JPW: Androgen deficiency in the aging male, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 27, p 861. Montague DK, Jarow J, Broderick GA, et al: The management of erectile dysfunction: An update. MANAGEMENT OF ERECTILE DYSFUNCTION GUIDELINE. American Urological Association Education and Research, Inc, 2005. <a href='http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines.cfm?sub=ed' target='_new'><u>http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines.cfm?sub=ed</u></a>

2012 - 127 A 62-year-old man with Klinefelter Syndrome underwent a mastectomy for breast cancer three months ago. He complains of decreased energy and decreased libido. A total testosterone is 210 ng/dl and LH is 15 IU/l. The next step is therapy with: A. oral phosphodiesterase inhibitors. B. low dose transdermal estrogen. C. aromatase inhibitors. D. testosterone. E. beta-hCG.

C . Men with Klinefelter Syndrome are at increased risk for the development of breast cancer. Approximately 80% of cases are estrogen receptor positive, therefore any treatment that increases estrogen levels is contraindicated unless the patient is cured of breast cancer. This patient has symptomatic hypogonadism which would benefit from an increase in serum testosterone but he was recently treated for breast cancer. In men a portion of testosterone is converted to estradiol, primarily in adipose tissue. Aromatase inhibition will decrease conversion of testosterone to estrogen thereby raising testosterone levels while at the same time decreasing estrogen levels. This is safe in men with breast cancer. Phosphodiesterase inhibitors are indicated for erectile dysfunction which this patient does not complain of. Estrogen therapy has no role in treating these symptoms in men and risks stimulation of breast cancer cell growth. HCG will increase testicular production of testosterone. The increased peripheral testosterone levels from either HCG or testosterone therapy will result in increased estrogen levels due to the peripheral conversion to estrogen. Therefore these are inappropriate therapies in men with breast cancer. In Kleinfelters, patients without breast cancer, standard treatment of hypogonadism with testosterone replacement is safe. Morales A, Morley J, Heaton JPW: Androgen deficiency in the aging male, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 27, p 859. Dimitrov NV, Colucci P, Nagpa L: Some aspects of the endocrine profile and management of hormone-dependent male breast cancer. THE ONCOLOGIST 2007;12:798-807. Cutuli B, Le-Nir CC, Serin D, et al: Male breast cancer. Evolution of treatment and prognostic factors. Analysis of 489 cases. CRITICAL REVIEWS IN ONCOLOGY/HEMATOLOGY 2010;73:246-254.

2008 - 38 A 32-year-old man with congenital bilateral absence of the vas deferens desires a biological child. Testing for the cystic fibrosis transmembrane conductance regulator (CFTR) gene is negative. The next step is: A. test the man's parents for the CFTR gene. B. proceed with testicular sperm extraction and ICSI. C. CFTR testing of his wife. D. proceed with testicular sperm extraction and ICSI and do pre-implantation genetic diagnosis. E. CFTR testing of the man's sperm.

C . Mutations in the cystic fibrosis transmembrane conductance regulator gene are responsible for a phenotypic spectrum from overt cystic fibrosis to congenital bilateral absence of the vas deferens. Over 1000 CFTR mutations have been identified and only a portion are detected by routine testing. The man should be assumed to be a CFTR carrier, and his wife needs to be tested to determine the risk of cystic fibrosis in their offspring. Jarow JP, Sharlip ID, Belker AM, et al: Best practice policies for male infertility. J UROL 2002;167:2138-2144.

2012 - 62 Homologous natural cycle artificial insemination for couples with male factor infertility due to oligoasthenospermia is: A. only effective if placed intracervically. B. only effective if placed intrauterine. C. no more effective than timed vaginal intercourse. D. most effective in women with tubal disorders. E. most useful with counts of < 10 million per ejaculate.

C . Natural cycle refers to allowing the woman to ovulate on her own without pharmaceutical induced stimulation of the development of multiple follicles through ovulation induction. In men with male factor infertility due to abnormal semen parameters, natural cycle intracervical or intrauterine insemination (IUI) is no better than timed vaginal intercourse. Those techniques are only useful in infertility caused by mechanical problems such as hypospadias, retrograde ejaculation, or impotence. Natural cycle IUI is useful in pure cervical factor infertility. Pregnancy rates with IUI are increased in couples with abnormal semen parameters if the woman undergoes ovulation induction. Clomiphene citrate and gonadotropins are commonly used medications for ovulation induction. Women with tubal abnormalities are best treated with in vitro fertilization since inseminated sperm still need to ascend through the fallopian tubes. The higher the total motile sperm count the better the pregnancy rate, therefore those with a sperm count > 10 million will fare better than those with < 10 million. Sigman M, Jarow JP: Male infertility, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 19, p 651.

2012 - 82 A 28-year-old woman has significantly decreased libido six months after starting oral contraceptive pills. The most likely cause of her decreased sexual desire is: A. reduced serum estradiol. B. reduced serum progesterone. C. reduced serum testosterone. D. decreased sex hormone binding globulin. E. increased serum prolactin.

C . Oral contraceptive pills (OCPs) significantly increase the production and release of sex hormone binding globulin (SHBG) by the liver. The increased SHBG subsequently lowers serum free testosterone by irreversible binding. Low levels of circulating free testosterone can cause a significant decrease in sexual desire/libido. While estradiol may decrease with OCPs, the effect is less striking on libido than the effect of a lower serum testosterone. Progesterone levels may actually increase with some OCPs. Goldstein I: Urologic management of women with sexual health concerns, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 28, pp 867-868.

2012 - 103 A six-month-old infant with severe pulmonary hypertension is on I.V. sildenafil at the dose of 1.2 mg/kg every six hours. After two days, he is successfully weaned off inhaled nitric oxide. He develops a sustained erection that has lasted 12 hours. The next step is: A. observation. B. discontinue I.V. sildenafil. C. lower I.V. sildenafil dose. D. switch to oral sildenafil. E. re-initiate inhaled nitric oxide.

C . Sildenafil has been very effective in treating pulmonary hypertension in infants and adults and was approved by the FDA in 2005. Many multi-institutional studies have demonstrated its safety and efficacy in this population. Doses for treatment of pulmonary hypertension are much higher than doses used to treat erectile dysfunction (po - 100 mg TID in children and adults, IV 1.2 mg/kg I.V.). This has led to a higher incidence of adverse events including dizziness, headache, flushing, rhinitis and prolonged erection. There have been several reports of prolonged erection in children using high I.V. doses. These patients have responded to simply lowering the dose of sildenafil. This patient has shown an excellent response to treatment with I.V. sildenafil (since he has been successfully weaned off inspired nitric oxide) of his life-threatening pulmonary hypertension and it should be continued. Observation is not appropriate with a prolonged erection of this type. No data is available on either switching to oral administration or to a different PDE5 inhibitor. Huddleston A, Knoderer C, Morris J, Ebenroth, E: Sildenafil for the treatment of pulmonary hypertension in pediatric patients. PED CARD 2009;30:875-878.

2011 - 109 A 32-year-old man has painful ischemic priapism lasting 36 hours and undergoes a unilateral cavernosal glanular shunt (T-shunt). In the operating room he becomes flaccid but his erection recurs within ten minutes. The next step is: A. observation and pain management. B. irrigate with phenylephrine. C. contralateral T-shunt. D. cavernosal-spongiosal shunt. E. cavernosal-saphenous vein shunt.

C . The T-shunt is a cavernosal-glanular shunt that is a simple shunt for the treatment of ischemic priapism. It has demonstrated success even after prolonged periods of ischemic erection with the majority of men preserving erectile function following treatment. An 11-blade is inserted through the glans and into the distal corpus cavernosum. It is then rotated 90 degrees and removed creating the T. A Hegar dilator is then inserted into the incision and dilated down the length of the corpora. The penis is observed in the operating room for 15 minutes and if it remains flaccid a unilateral procedure is adequate. Should the erection return the next step is a bilateral procedure. Observation would not be appropriate at his time and irrigation would not be effective. A more proximal shunt is not indicated until continued failure of the T-shunt. Burnett AL: Priapism, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 26, pp 846-848. Brant WO, Garcia MM, Bella AJ, et al: T-shaped shunt and intracavernous tunneling for prolonged ischemic priapism. J UROL 2009;181:1699-1705. Montague DK, Jarow J, Broderick GA, et al: Guideline on the management of priapism. MANAGEMENT OF PRIAPISM GUIDELINE. American Urological Association Education and Research, Inc, 2003. http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines.cfm?sub=priapism

2008 - 62 Luteinizing hormone (LH) timed intrauterine insemination would most likely benefit subfertile couples with: A. significant levels of male antisperm antibodies. B. severe oligospermia. C. cervical stenosis and low semen volume. D. asthenospermia. E. cervical incompetence.

C . The cervical mucus is a major barrier to sperm that are poorly motile in the oligospermic man. From a naive viewpoint it would seem that bypassing this biological barrier by intrauterine insemination would be highly successful form of therapy for the subfertile man. Motility and transport though the cervical mucus represent only a small portion of the many complex functions of which sperm must be capable for fertilization and early embryonic development to occur. Therefore, it is not surprising that intrauterine insemination is not effective universally in couples with male factor infertility. The placement of sperm directly into the uterine cavity, carefully timed to ovulation, will not compensate for acrosomal defects and abnormalities of sperm-egg interaction, which are common in men with oligospermia. Nevertheless, sperm processing and intrauterine insemination can have an appropriate role in the management of carefully selected subfertile couples. It is an ideal form of therapy for cervical factor infertility and for men with retrograde ejaculation and significant semen volume abnormalities. Men with significant levels of antisperm antibodies and fewer than 2 million motile sperm after washing are not likely to achieve conception with intrauterine insemination. Sigman M, Jarow JP: Male infertility, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 19, p 651.

2013 - 17 A 43-year-old man desires a biological child with his 38-year-old wife. Both testes are 5 cm in longitudinal axis and firm on physical examination. Two semen analyses show azoospermia with volumes of 2.1 and 2.3 ml. FSH is 2.8 IU/l. The next step is: A. adoption. B. TRUS. C. evaluation of the wife. D. testicular sperm extraction with ICSI. E. microsurgical scrotal ductal reconstruction.

C . The likelihood of obstructive azoospermia is 96% with testis longitudinal axis greater than 4.6 cm and FSH less than 7.6 IU/l. However, the most significant predictor of any form of reproductive intervention is maternal age, with female fecundity declining precipitously after age 37. The decision to perform microsurgical scrotal ductal reconstruction or to obtain sperm from the testis for IVF and intracytoplasmic sperm injection rests on evaluation of the female partner, especially after age 37. Transrectal ultrasound is not necessary if semen volumes are normal (> 1.5 ml) as ejaculatory ductal obstruction is unlikely. Sabanegh E, Agarwal A: Male infertility, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 1, chap 21, pp 619, 635.

2012 - 148 A 35-year-old man has primary infertility. On physical exam, neither vas deferens is palpable, each testis is 34 ml in volume. Semen analysis reveals a 0.3 ml volume and azoospermia. The man and his wife would like to pursue all options for parenthood. The next step is: A. scrotal ultrasound. B. Y-chromosome microdeletion analysis and karyotype. C. cystic fibrosis mutation analysis on both partners. D. diagnostic testicular biopsy with scrotal exploration. E. donor sperm intrauterine insemination.

C . The majority of patients with congenital bilateral absence of the vas deferens (CBAVD) are found to have mutations or 5T polymorphism of the CFTR (cystic fibrosis transmembrane regulator protein) gene. Men with CBAVD may have subtle pulmonary disfunction such as recurrent bronchitis and other family members may carry CF mutations, therefore the man should be offered CF testing. If the female partner has a CF mutation, the couple's children have a 50% chance of having mutations in both CF genes and developing clinical cystic fibrosis. CF testing of both partners is ideal if the couple is considering sperm retrieval and ICSI. Diagnostic testicular biopsy is not necessary since CBAVD is associated with obstructive azoospermia. Scrotal exploration will not find the vas deferens. CBAVD patients should have normal karyotypes and will not have AZF deletions of the Y-chromosome. Scrotal ultrasound will not add any useful information. While donor insemination is an option, it is not the next step if the couple is considering all options. Jarow J, Sigman M, Kolettis PN, et al: The evaluation of the azoospermic male. EVALUATION OF THE AZOOSPERMIC MALE BEST PRACTICE STATEMENT. American Urological Association Education and Research, Inc, 2010. <a href='http://www.auanet.org/content/media/azoospermicmale2010.pdf' target='_new'><u>http://www.auanet.org/content/media/azoospermicmale2010.pdf</u></a>

2014 - 56 A 26-year-old infertile body builder with a five year history of heavy anabolic steroid use is azoospermic 12 months after discontinuing all steroids. His serum testosterone is 150 ng/dl and FSH is normal. The next step is: A. observation. B. testosterone replacement. C. hCG. D. testicular biopsy. E. clomiphene citrate.

C . The non-medical use of anabolic steroids by athletes is potentially a significant cause of infertility in male adolescents and adults. It has been estimated that 3-12% of male athletes of high school age in the United States have used steroids. Infertility associated with anabolic steroid use commonly presents as oligospermia or azoospermia along with abnormalities of sperm motility and morphology. As with many of the other steroid side effects, the semen parameter deficits are thought to be reversible and consequently, the discontinuation of all steroids is the first course of therapy. Unfortunately, some steroid abusers develop a chronic anabolic-induced hypogonadism syndrome/state. Successful gonadotropin (hCG) replacement is the best therapy when this occurs. This patient has already been off steroids with no return of sperm after one year, therefore, continued observation is not likely to work at this point and a trial of hCG therapy is indicated. Testosterone supplementation will only continue to suppress the central axis (decrease FSH and LH release) and perpetuate the problem. Clomiphene citrate might work by blocking testosterone and estradiol feedback on the central axis and stimulate LH/FSH release, but will not be as effective as hCG. Testis biopsy is not needed at this time, but might be needed if the patient does not respond to hormonal manipulation and maturation arrest is suspected.

2014 - 35 A 26-year-old infertile man has an ejaculate volume of 0.9 ml, sperm count of 10 million/ml, and 20% motility. Physical examination and hormonal evaluation are normal. The next step is: A. antisperm antibody testing. B. semen culture. C. post-ejaculatory urinalysis. D. TRUS. E. scrotal Doppler ultrasonography.

C . The patient's evaluation reveals oligoasthenospermia with low ejaculate volume without any obvious cause. Post-ejaculatory urinalysis (PEU) is the best next step in order to identify a correctable cause for this patient's semen abnormalities. Hamster egg penetration test and antisperm antibody testing are useful for prognostic purposes but will not identify a correctable abnormality. Post-coital test is helpful in patients with isolated volume problems but would not be helpful in patients with oligoasthenospermia. Scrotal ultrasonography for subclinical varicocele is not indicated. TRUS may be considered if the PEU is negative but should not be considered first since it is more invasive than a PEU.

2011 - 65 A 42-year-old man with azoospermia and primary infertility has an FSH of 15 IU/l, small volume testes, and an otherwise normal physical examination. The factor that most reliability predicts his ability to have a biologic child is: A. vasography. B. serum FSH. C. wife's fertility. D. testicular volume. E. testicular biopsy.

C . The presence of small volume testes with an elevated FSH suggests the presence of non-obstructive azoospermia. Most men with non-obstructive azoospermia will have sperm retrievable from the testes that can be used in conjunction with in vitro fertilization for the wife. The most important characteristic to determine eligibility for treatment will be the wife's age and fertility. Screening for obstruction (with vasography) is not of value. Carpi A, Sabanegh E, Mechanick J: Controversies in the management of nonobstructive azoospermia. FERT STERIL 2009;91:963-970. Epub 2009 Mar 21. Devroey P, Liu J, Nagy Z, et al: Pregnancies after testicular sperm extraction and intracytoplasmic sperm injection in non-obstructive azoospermia. HUM REPROD 1995;10:1457-1460.

2009 - 70 A 20-year-old man undergoes a distal shunt (Al-Ghorab) for venocclusive priapism. Four hours later, he has a 70% rigid erection. The next step is: A. proximal cavernosal-spongiosal shunt. B. intracorporal phenylephrine administration. C. corporal blood gas analysis. D. pudendal arteriography. E. cavernosal-saphenous vein shunt.

C . The purpose of a shunt procedure for venocclusive priapism is to oxygenate the penis. Often residual corporal smooth muscle paralysis and edema will leave the patient's penis tumesced and sometimes rigid. Following an Al-Ghorab shunt, grasping the penis at its base and squeezing will reduce arterial inflow and should result in detumescence, if the shunt is open. Confirmation can be made by drawing a blood gas and proving arterial oxygen levels. This should be done before returning to the operating room for a second procedure. An alternative approach would be to perform a penile duplex ultrasound to demonstrate any arterial inflow. Burnett AL: Priapism, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 26, p 839.

2014 - 130 A 56-year-old obese man with a history of depression has a total testosterone of 450 ng/dl. Free testosterone level measured by an analog assay (immunoassay) is low. Physical exam is unremarkable. The next step is: A. measure estradiol. B. measure LH and prolactin. C. measure bioavailable testosterone. D. testosterone replacement therapy. E. aromatase inhibitor therapy.

C . While this patient has depression, this is not specific for testosterone deficiency, and low testosterone should be demonstrated before initiating therapy. The patient has a normal total testosterone but a low free testosterone measured by an analog assay. The gold standard techniques for measurement of free testosterone are ultracentrifugation or equilibrium dialysis. Immunoassays, while convenient and widely available, utilize a testosterone analog and do not give accurate results. Measurement of bioavailable testosterone or free testosterone measured by ultracentrifugation or dialysis should be utilized. Calculated free testosterone which utilizes the total testosterone, sex hormone binding globulin with or without albumin levels, may also be used if the prior tests are not available. Determination of LH and prolactin may be indicated with low total testosterone levels to differentiate between primary and secondary hypogonadism. Since the total testosterone is normal, there is no role for LH or prolactin determination in this patient. While estradiol does increase with obesity, there is no indication for measurement of estradiol in this patient. Aromatase inhibitors are often used off label in patients with elevated estradiol levels and symptomatic gynecomastia. This is second line therapy and should not be initial therapy in most patients since long term safety has not been assessed. Long term use of aromatase inhibitors may result in elevation of liver function tests and affect bone health. Testosterone replacement therapy should not be instituted without demonstrating a low testosterone level.

2011 - 41 A 40-year-old man underwent a vasectomy ten years earlier. He undergoes vasoepididymostomy, and sperm are noted in the epididymis. Six months after this procedure, semen analysis reveals azoospermia. The next step is: A. repeat vasoepididymostomy. B. epididymal sperm aspiration and ICSI. C. testis biopsy. D. repeat semen analysis in three months. E. donor insemination.

D . Delayed return of sperm in the ejaculate may occur after vasoepididymostomy. Men without sperm in the epididymal fluid at the time of the anastomosis will never recover sperm in the ejaculate. Forty-one percent of patients will have delayed appearance of sperm in the ejaculate which can take up to one year or longer. The ultimate mean sperm count will be similar in those with immediate and delayed return of sperm. Delayed anastomotic obstruction is also the same in both groups. Yang G, Walsh TJ, Shefi S, Turek PJ: The kinetics of the return of motile sperm to the ejaculate after vasectomy reversal. J UROL 2007;177:2272-2276. Jarow JP, Sigman M, Buch JP, Oates RD: Delayed appearance of sperm after end-to-side vasoepididymostomy. J UROL 1995;153:1156.

2009 - 2 A very tall 24-year-old man with primary infertility has slight gynecomastia and disproportionately long arms. He has a normal male pattern of hair distribution in his pubic area and axillae. His testes are 3 ml and firm bilaterally. His sperm concentration is 0.5 million/ml. Genetic analysis will most likely show: A. microdeletions of the Y chromosome. B. 46, XX karyotype. C. 47, XXY karyotype. D. 50% 46, XY; 50% 47, XXY karyotype. E. 45, XO karyotype.

D . Genetic abnormalities commonly associated with severely abnormal sperm production include microdeletions of the Y chromosome, classic Klinefelter's syndrome, or mosaic Klinefelter's syndrome. A 45,XO karyotype is associated with Turner's syndrome (gonadal dysgenesis) in phenotypic women. Men with microdeletions of the Y chromosome typically have a normal appearance. The phenotypic appearance of this patient is most consistent with Klinefelter's syndrome. Men with classic Klinefelter's syndrome are almost always azoospermic, suggesting that this patient most likely has a mosaic form of this syndrome. Lanfranco F, Kamischke A, Zitzmann M, Nieschlag E: Klinefelter's syndrome. LANCET 2004;364(9430):273-283.

2013 - 20 A 28-year-old man with Kallmann syndrome is treated with exogenous testosterone. He desires a biological child. Semen analysis reveals a volume of 2.2 ml and azoospermia. The next step is: A. post-ejaculate urinalysis. B. assay testosterone, LH, and FSH. C. administer GnRH. D. administer hCG and recombinant FSH. E. testicular sperm extraction for IVF.

D . Kallmann syndrome, anosmia or hyposmia associated with hypogonadotropic hypogonadism is commonly diagnosed due to a delayed onset of puberty. Most patients are treated with exogenous testosterone at the time of their diagnosis for virilization. Testosterone is easy and cost effective to administer compared to daily injections of alternative hormones. Azoospermia in these patients results from the combination of inadequate levels of intratesticular testosterone, and the patient's natural absence of stimulatory pituitary hormones. When the patient desires to father children, spermatogenesis can be brought about by discontinuing parenteral testosterone and beginning daily IM or SQ injections of hCG and recombinant FSH. If the response is insufficient, GnRH administration may be considered but is expensive and requires I.V. administration. In patients with low ejaculate volume (< 1.5 ml), a post-ejaculate urine is useful to diagnose retrograde ejaculation, this patient's ejaculate volume is normal. Assay of testosterone, LH and FSH is not needed in this patient in whom a diagnosis of Kallmann syndrome has already been made. It would be inappropriate to proceed with testicular sperm extraction without first giving the hormonal treatment necessary to stimulate spermatogenesis. Sabanegh E, Agarwal A: Male infertility, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 1, chap 21, p 639.

2014 - 41 Pyospermia in an infertile man commonly suggests: A. a sexually transmitted infection. B. UTI. C. antisperm antibodies. D. functional sperm damage. E. failure to retract foreskin.

D . Leukocytes are often present in the semen of infertile men. They are seldom due to documentable infection or antisperm antibodies. They do often indicate functional damage from DNA fragmentation to sperm membrane lipid peroxidation from reactive oxygen species released from the leukocytes. Leukocytes can occur with UTIs, but unless urine is in the semen, this is an unlikely source. Sexual transmitted infections can also lead to leukocytes in semen and this does need to be ruled-out, however, even PCR DNA testing for sexual transmitted pathogens are often negative verifying the situation is most commonly idiopathic.

2011 - 77 The primary advantage of using frozen semen rather than fresh semen for in vitro fertilization with donor sperm is: A. improved implantation rates. B. improvement in embryonic vitality scores. C. increased number of cryopreservable spare embryos. D. decreased risk of HIV transmission. E. decreased number of insemination cycles required to achieve a pregnancy.

D . Recent concerns over the transmission of sexually transmitted diseases by donor insemination have led to the use of frozen donor sperm, which permits quarantine of frozen sperm with re-screening of donors. The disadvantage of this increased safety is a lower per cycle pregnancy rate with intrauterine insemination, largely due to decreased motility of frozen-thawed donor sperm. The number of insemination cycles required to achieve a pregnancy may increase, although the cumulative pregnancy rates appear to be the same as with fresh semen. In contrast, use of frozen donor sperm with in vitro fertilization does not affect implantation rates, embryonic vitality scores or the number of spare embryos. Anger JT, Gilbert Br, Goldstein M: Cryopreservation of sperm: Indications, methods, and results. J UROL 2003,170:1081-1082.

2010 - 5 A 48-year-old man and his 44-year-old wife wish to have another child. Fifteen years previously, he had a vasectomy and four years ago he failed vasectomy reversal. No sperm were found in the vas at the time of surgery. The wife's menses are regular. The best chance for pregnancy is: A. open epididymal aspiration with IVF and ICSI. B. needle aspiration of the testicle with IVF and ICSI. C. gynecologic evaluation of wife then bilateral vasoepididymostomy if her evaluation is normal. D. donor eggs and needle aspiration of the testicle with IVF and ICSI. E. re-do microscopic two-layer vasovasostomy.

D . Results of standard IVF or ICSI are extremely poor in women over age 40. Current data demonstrate a 4% live birth rate per cycle in 44 year old women. With donor eggs the pregnancy rate is approximately 50%. The overall rate of pregnancy after vasoepididymostomy is 30-50% but is dramatically lower with a wife of age 40. Assisted Reproductive Technology (ART) Report: Section 4-ART cycles using donor eggs. Centers for Disease Control and Prevention, 2006, figure 44. http://www.cdc.gov/ART/ART2006/sect4_fig44-48.htm#f45 Gerrard ER Jr, Sandlow JI, Oster RA, et al: Effect of female partner age on pregnancy rates after vasectomy reversal. FERTIL STERIL 2007;87:1340-1344.

2009 - 79 A patient with non-ischemic priapism is to undergo duplex Doppler ultrasonography to confirm the diagnosis. The ultrasonographer should scan the: A. ventral penile shaft. B. dorsal penile shaft. C. perineum. D. perineum and ventral penile shaft. E. perineum and dorsal penile shaft.

D . The diagnosis of non-ischemic priapism can be confirmed by using duplex Doppler ultrasonography. While the mechanism of injury may guide the clinician to the location of the arterio-corporal fistula, perineal or penile, the ultrasound should assess the penis and perineum. Ultrasonography of the penis to assess cavernosal artery morphology and dynamics is conducted on the ventral surface of the penis in a sagittal, para-urethral plane. Burnett AL: Priapism, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 26, p 845.

2010 - 26 A 38-year-old azoospermic man with secondary infertility has an ejaculate volume of 0.3 ml. Post ejaculate urine contains no sperm. Serum testosterone and FSH are normal, both vasa are palpable, and testicular volume is normal. Transrectal ultrasonography reveals a normal prostate, ejaculatory ducts, and dilated seminal vesicles. The next step is: A. ejaculatory duct cannulation. B. testis biopsy. C. vasography. D. seminal vesicle aspiration. E. renal ultrasound.

D . The differential diagnosis of low ejaculate volume azoospermia is ejaculatory duct obstruction, hypogonadism, vasal agenesis, ejaculatory failure, and testicular failure. Hypogonadism was excluded by a normal testosterone level and the patient has palpable vasa. Retrograde ejaculation is not present because no sperm are in the post-ejaculate urine. This patient has either testicular failure or an obstruction of the ejaculatory ducts. Seminal vesicle aspiration under transrectal ultrasound guidance will reveal numerous sperm if obstruction is present and is the least invasive method to diagnose this treatable lesion. Ejaculatory duct cannulation is difficult and thus may not diagnose the problem. Jarow J, Sharlip ID, Belker AM, et al: Report on evaluation of the azoospermic male: An AUA best practice policy and ASRM Practice Committee report. AZOOSPERMIC MALE BEST PRACTICE STATEMENT. American Urological Association Education and Research, Inc, 2001, pp 3-6. http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines/main-reports/azoospermicmale.pdf

2010 - 136 A 24-year-old infertile man has a normal physical examination, serum testosterone of 340 ng/dl and isolated oligospermia with normal volume on two semen analyses. His wife's evaluation is normal. The next step is: A. repeat semen analysis. B. antisperm antibody testing. C. scrotal ultrasound. D. intrauterine insemination. E. adoption.

D . The patient has oligospermia. No correctable abnormalities are present. Further evaluation with ultrasonography for a subclinical varicocele is not helpful. Since two semen analyses show the same defects, a repeat semen analysis will be of no value. If the two analyses were discrepant, another specimen would be useful. No indication for antisperm antibody testing is present. Intrauterine insemination is most effective for cervical-factor infertility or isolated oligospermia. Sigman M, Jarow JP: Male infertility, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 19, p 622, 651.

2014 - 112 A 19-year-old man complains that his partner has noticed significant left lateral deviation of his penis on erection. He denies any penile trauma and has not previously noticed the curvature. The most likely diagnosis is: A. Peyronie's disease. B. subacute penile fracture. C. acquired penile curvature. D. congenital penile curvature. E. hypospadias with chordee.

D . This patient has congenital penile curvature which is often noticed in the postpubescent time period when the man becomes sexually active. Patients with congenital curvature of the penis can have ventral, lateral (most often to the left), or unusually, dorsal curvature. Photographs of the erect penis demonstrate a smooth curvature of the penile shaft. Patients usually are healthy young men classically presenting between the ages of 18 and 30 years old. Many of these patients have noticed curvature before passing through puberty but have presumed it to be normal. Evaluation is sought by the patient only when the abnormal curvature is brought to their attention from their sexual partner. There is usually no association with penile trauma which may lead to curvature from acute or subacute penile fracture and can cause acquired penile curvature. Peyronie's disease generally occurs in older men and is associated with pain on erection and gradual change in the degree of curvature. Another name for congenital penile curvature is chordee without hypospadias. Surgical repair, when necessary, is usually performed using a plication technique.

2013 - 112 A 52-year-old man in good health has a three year history of dorsal penile curvature. His angulation is 80 degrees and has been stable without pain for over a year. He has good erections with sildenafil but cannot penetrate due to the curvature. The best treatment is: A. oral colchicine. B. topical verapamil. C. corporal plication. D. plaque incision and graft. E. modeling and placement of inflatable penile prosthesis.

D . This patient has demonstrated a stable plaque in Peyronie's disease and is ready for surgical correction. Medical therapy with colchicine may be useful in the acute phase and will decrease penile pain, however it has little to no proven benefit over placebo in preventing curvature and is associated with significant GI side effects. It would not be effective in this clinical situation. Topical verapamil has not been adequately evaluated and would most likely not be effective with this degree of curvature. Plication would require multiple plicating sutures and would severely shorten the penis with this degree of curvature. Plication procedures are usually not recommended if the penile curvature is > 60 degrees due to significant shortening of the penis. As he gets excellent erections, a prosthesis is not yet indicated. Jordan GH, McCammon KA: Peyronie's disease, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 1, chap 28, pp 802-808.

2008 - 13 A distal urethral perforation occurs during insertion of a malleable penile prosthesis. The contralateral cylinder has not been placed. The next step is: A. place urethral catheter and complete the implantation. B. repair urethra and implant the contralateral prosthesis. C. repair urethra and place a suprapubic tube only. D. repair urethra, proceed with implantation, and place a suprapubic tube. E. place urethral catheter and terminate the procedure.

E . If urethral perforation occurs during dilation, it is best to abandon the procedure, divert the urine with a urethral catheter, and return at a later date. If the contralateral prosthesis has already been placed and there is no septal perforation, then it may be left in place. The urine should be diverted. Urethral repair would be difficult and is unnecessary. Montague DK: Prosthetic surgery for erectile dysfunction, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 23, p 797.

2011 - 106 A 32-year-old man has persistent penile pain three months after implantation of an inflatable penile prosthesis. Exam demonstrates no evidence of infection and a sigmoid deformity of the shaft with a cylinder palpable under the skin. The best treatment is: A. six weeks of oral antibiotics. B. six weeks of I.V. antibiotics. C. removal of prosthesis. D. downsizing of cylinders. E. patch graft to tunical albuginea.

D . When a penile prosthesis that is too long is implanted, the patient may complain of pain that does not subside as healing takes place after device implantation. Alternatively, it may lead to erosion of the rod either into the meatus or through the glans. Buckling may also cause erosion through the tunica albuginea. Reoperation with placement of smaller rods usually relieves the pain and avoids impending erosion. Cylinders that are too long may result in a sigmoid (S) penile deformity that might lead to premature cylinder failure. Antibiotic therapy will not improve his pain and patching the tear in the tunica albuginea will fail secondary to the oversized prosthesis. Montague DK: Prosthetic surgery for erectile dysfunction, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 23, pp 795-797.

2009 - 8 A 32-year-old man has azoospermia and semen volume of 3.1 ml. Both testes are 5.0 cm in longitudinal axis, and FSH is 3.8 mIU/ml (normal 2 - 12 mIU/ml). The next step is: A. scrotal ultrasound. B. clomiphene citrate. C. testis biopsy. D. scrotal exploration for microsurgical reconstruction. E. percutaneous epididymal sperm aspiration.

D . When testis longitudinal axis is > 4.5 cm and FSH is < 7.6 mIU/ml, 96% of azoospermic men will have obstructive azoospermia. Scrotal exploration for reconstruction may be directly undertaken without the need for a testis biopsy. Because the likelihood of epididymal obstruction requiring epididymovasostomy is high, percutaneous epididymal sperm aspiration should not be performed in these patients, as the epididymis may be permanently damaged preventing subsequent epididymovasostomy. Scrotal ultrasound is not sensitive enough to identify vasoepididymal obstruction, and clomiphene citrate would not be helpful in a patient with obstructive azoospermia. Schoor RA, Elhanbly S, Niederberger CS, Ross LS: The role of testicular biopsy in the modern management of male infertility. J UROL 2002;167:197-200.

2009 - 43 A 28-year-old man has the following hormone parameters: total testosterone 840 ng/d (normal 300-1000 ng/dl), prolactin 6 ng/ml (normal 1-15 ng/ml), LH 0.2 mIU/ml (normal 3-18 mIU/ml), FSH 0.4 mIU/ml (normal 1-15 mIU/ml). He is well-virilized but has testes that are 10 ml in volume bilaterally. The most likely diagnosis is: A. Kallmann syndrome. B. Klinefelter syndrome. C. Kartagener syndrome. D. exogenous testosterone use. E. bioinactive LH syndrome.

D . While low levels of pituitary gonadotropins are associated with Kallman's syndrome (absent gonadotropins, anosmia and midline defects), they are not associated with Klinefelter's syndrome where they are markedly elevated. The hormone pattern is not associated with either bioinactive LH (where levels are normal but LH is non-functional) or Kartagener syndrome. The suppressed gonadotropins, associated with good virilization and normal testosterone levels are a classic finding in men using exogenous testosterone. Schlegel PN, Hardy MP, Goldstein M: Male reproductive physiology, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 18, pp 577-578.

2009 - 5 A 47-year-old man underwent a vasectomy 16 years ago at the time of a hernia repair and recently married a 33-year-old woman who has never attempted to become pregnant. He has two grown children and now desires more children. Antisperm antibody titers are positive. The factor that portends a poor outcome after vasectomy reversal is: A. partner age > 30 years. B. previous inguinal surgery. C. partner has never been pregnant. D. presence of antisperm antibodies. E. long interval since vasectomy.

E . A gradual decline in success rates is seen with increasing intervals of obstruction, with pregnancy rates dropping below 50% after nine years. Delivery rates also decline significantly when the age of the partner is over 35 years. One study suggested that vasectomy at a younger age correlates with higher success rates, but this finding has yet to be validated by others. The significance of a positive antisperm antibody (ASA) status is controversial, but the high rate of successful vasectomy reversals despite the high incidence of ASA after vasectomy suggests that ASA status may not be a reliable prognostic factor. Hagler HM, Rotman M: Predictive parameters for microsurgical reconstruction. UROL CLIN N AM 2002;29:913-919.

2014 - 79 Elevation of the serum testosterone and LH levels associated with a normal FSH level is most frequently associated with: A. puberty. B. Klinefelter syndrome. C. secondary testicular failure. D. Sertoli-cell-only syndrome. E. androgen resistance.

E . Androgen resistance or testicular feminization syndrome presents with a wide range of phenotypes of complete female external genitalia to men with normal genitalia and abnormalities of spermatogenesis. This X linked disorder is due to an abnormality of the androgen receptor. Testosterone production and secretion by the Leydig cells is normal, but the target organs including the pituitary gland do not recognize it due to faulty receptors. Therefore, LH secretion is increased because of the apparent lack of testosterone while FSH is unaffected since it is controlled by inhibin. Puberty would have normal testosterone, LH, and FSH. Klinefelter Syndrome and Sertoli Cell Only Syndrome would have elevated FSH, LH, and low testosterone. Secondary testicular failure can have a multitude of etiologies with the end result being low testosterone. The FSH and LH may be high or low.

2012 - 76 Autoinflation of an inflatable penile prosthesis is best prevented by: A. use of a smaller reservoir. B. postoperative partial cylinder inflation. C. intraperitoneal reservoir placement. D. reservoir placement in subinguinal canal. E. use of a reservoir with a lockout valve.

E . Autoinflation occurs when the inflatable penile prosthesis partially inflates with physical activity. It can be minimized by placing the reservoir in the prevesical (retropubic) space performing the back pressure test with reservoirs that do not have a lockout valve or by using a reservoir with a lock-out valve, is now available as an option. The cylinders should also be kept deflated during healing after surgery and when the prosthesis is not being used. Initial experience with this device suggests that it reduces the incidence of this complication. Montague DK: Prosthetic surgery for erectile dysfunction, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 23, pp 795-797.

2011 - 82 A man with erectile dysfunction, diabetes, and an associated autonomic neuropathy complains of debilitating diplopia with sildenafil despite obtaining an excellent erectile response. He should be advised to discontinue sildenafil and: A. seek an ophthalmologic consultation. B. use intracavernosal injections. C. use an intra-urethral suppository. D. use vardenafil. E. use tadalafil.

E . Diplopia, blurred vision and loss of color vision (chromatopsia) is related to cross activity that some PDE5 inhibitors have for PDE6, the retinal phototransduction enzyme. This is most pronounced with sildenafil and vardenafil and is rarely associated with tadalafil as the latter has very little affinity for PDE6. An ophthalmologic consultation is not required as the adverse event is well documented. An ophthalmologist should be seen for loss of visual acuity or blindness. The fact that the patient responded well to a sildenafil illustrates that his autonomic neuropathy is minimal and the need for more invasive treatments such as transurethral PGE1 suppository or intracavernosal injection therapy is low. Penile pain due to PGE1 suppository or PGE1 injection monotherapy may be experienced. Lue TF, Broderick GA: Evaluation of nonsurgical management of erectile dysfunction and premature ejaculation, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 22, p 776.

2013 - 91 A 52-year-old man with renal insufficiency has decreased libido and progressive erectile dysfunction. He has a spot serum prolactin level of 220 ng/ml (normal 5-20 ng/ml). The next step is: A. measure serum testosterone. B. measure FSH and LH. C. brain CT. D. nephrology consult. E. ophthalmology consult.

E . Elevated prolactin levels can cause infertility and sexual dysfunction by decreasing the production of testosterone. Mildly elevated levels (< 50ng/ml) can be seen with stress and renal insufficiency. Persistently high levels of serum prolactin are suggestive of a pituitary adenoma and need to be evaluated with a careful measurement of visual fields and an MRI of the pituitary. This patient has levels consistent with a pituitary adenoma and serum testosterone, FSH and LH will not help make the diagnosis. While he may benefit from the care of a nephrologist, it will not direct the diagnosis and treatment of a pituitary adenoma. CT is not specific enough for an evaluation of the pituitary and the best choice is an ophthalmology consult for careful visual field testing and an MRI of the pituitary. Sabanegh E, Agarwal A: Male infertility, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 1, chap 21, p 639.

2010 - 4 A 47-year-old man with diabetes mellitus has erectile dysfunction, decreased vibratory sensation in his feet and fasting blood sugars over 300 mg/dl. The best treatment of his erectile dysfunction is: A. exogenous testosterone. B. exogenous gonadotropins. C. improved diabetic control. D. a daily Vitamin B complex. E. penile prosthesis.

E . Exogenous androgen, gonadotropin and vitamin therapy do not restore potency in the diabetic male. Even with good control of the underlying diabetes, erectile dysfunction usually persists. Alternative therapies such as sildenafil citrate, intracavernous injection therapy, and a vacuum erection device can also be effective in many of these patients. Some diabetic patients will ultimately require a penile prosthesis. Lue TF: Physiology of penile erection and pathophysiology of erectile dysfunction, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 21, pp 746-747.

2014 - 13 A distal urethral perforation occurs during insertion of a malleable penile prosthesis. The contralateral cylinder has not been placed. The next step is: A. place urethral catheter and complete the implantation. B. repair urethra and implant the contralateral prosthesis. C. repair urethra and place a suprapubic tube only. D. repair urethra, proceed with implantation, and place a suprapubic tube. E. place urethral catheter and terminate the procedure.

E . If urethral perforation occurs during dilation, it is best to abandon the procedure, divert the urine with a urethral catheter, and return at a later date. If the contralateral cylinder has already been placed and there is no septal perforation, then it may be left in place. The urine should be diverted. Urethral repair would be difficult and is unnecessary. Should this occur with an inflatable prosthesis, the entire device should be removed and the urethra allowed to heal.

2008 - 10 In patients with organic erectile dysfunction, the best response to sildenafil citrate is achieved in those with: A. vascular disease. B. prior radical prostatectomy. C. diabetes mellitus. D. prior TURP. E. spinal cord injury.

E . Improved erections with sildenafil treatment were noted in 70% of men with organic erectile dysfunction and in over 80% of men with psychogenic erectile dysfunction. When the response is stratified by specific disease states, the best response rates are noted in the spinal cord injury group (83%). The response rates for the other groups range from 50-70%. Lue TF, Broderick GA: Evaluation of nonsurgical management of erectile dysfunction and premature ejaculation, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 22, p 775.

2009 - 82 A 28-year-old white male who is sexually active has recurrent episodes of priapism requiring visits to the emergency department. The best treatment is: A. terbutaline. B. LH-RH agonist. C. digoxin. D. baclofen. E. home intracavernosal phenyephrine.

E . In men with recurrent bouts of priapism and concerned about their sexual function, the use of an LH-RH agonist is problematic. In this situation, training the patient to use intracavernosally delivered phenylephrine is advisable. For a man of any age who is not concerned about sexual function, the use of an LH-RH agonist has been shown to be of benefit. The literature supporting the use of oral terbutaline, digoxin, or baclofen is anecdotal. Lue TF, Broderick GA: Evaluation of nonsurgical management of erectile dysfunction and premature ejaculation, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 22, p 750.

2010 - 54 A 27-year-old man evaluated for infertility of nine months duration has a normal sperm count and motility, but sperm morphology reveals only round headed sperm. Testis volume is normal bilaterally, serum FSH is within normal limits, and he has a moderate sized left unilateral varicocele. His wife is 25-years-old, and has a normal evaluation. The next step is: A. varicocele repair. B. intrauterine insemination. C. re-evaluation in three months. D. in vitro fertilization. E. ICSI.

E . Observation is a reasonable choice in young couples with infertility of less than one year's duration. However, the finding of round headed sperm is consistent with absence of the acrosome and individuals with this finding are sterile. Standard intrauterine inseminations and in vitro fertilization are unsuccessful because the sperm cannot fertilize an egg without a normal acrosome. Varicocele repair will not improve the morphology. The only method that will induce a pregnancy using the patient's sperm is in vitro fertilization using intracytoplasmic sperm injection (ICSI). Even regular ICSI has resulted in low pregnancy rates. Current approaches combine assisted oocyte activation with ICSI. The alternative is donor insemination. Tejera A, Molla M, Muriel L, et al: Successful pregnancy and childbirth after intracytoplasmic sperm injection with calcium ionophore oocyte activation in a globozoospermic patient. FERTIL STERIL 2008;90:1202-1205. Meacham RB, Chemes H, Carrell D, Goldstein M: Globozoospermia: Is there a role for varicocele repair? J ANDROL 2007;28:490.

2013 - 82 A 46-year-old-man has a sustained erection for 72 hours. His erection has persisted despite irrigation with dilute phenylephrine solution through multiple glanular punctures and a subsequent corporal-cavernosal shunt. One day later, he continues to have a rigid penis. The best treatment is: A. oral terbutaline. B. oral bicalutamide. C. corporal-glanular shunt. D. bilateral T-shunt. E. immediate prosthesis implantation.

E . Priapism lasting longer than 36 hours recalcitrant to multiple attempts at irrigation as well as shunting procedures, is best treated with immediate penile prosthesis implantation. While immediate implantation carries a greater risk of infection and erosion, it preserves penile length and makes prosthesis implantation easier. In this severe case of ischemic priapism, oral therapies are not indicated and he has already failed a proximal shunting procedure. A T-shunt is another form of a distal corporal-glanular shunt. A repeat proximal shunt would not be unreasonable in this individual, but would have a low chance of success and will likely be associated with significant penile shortening and fibrosis. Broderick GA: Priapism, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 1, chap 25, pp 764-766.

2009 - 41 A 22-year-old woman has a blood pressure of 160/110 mm Hg. Her serum potassium is 2.4 mEq/l while her other serum electrolytes are normal. CT scan demonstrates a 2 cm peripheral renal mass with a normal contralateral kidney. Plasma renin activity is 6.4 ng/ml/hr (normal 0.5-1.6 ng/ml/hr). The next step is: A. renal angiography. B. renal venous renin sampling. C. captopril renogram. D. radical nephrectomy. E. partial nephrectomy.

E . Reninomas are rare renal tumors associated with hypertension, hypokalemia, and a solid small renal mass. The critical test is plasma renin activity that is usually extremely high. Almost all are shown on CT scan as a hypodense mass that is hypovascular. In most cases, it is not necessary to control the renal pedicle and an arteriogram is not mandatory. The patient should be treated with nephron sparing surgery, i.e. resection or partial nephrectomy because these tumors are benign in nature. Campbell SC, Novick AD, Bukowski RM: Renal tumors, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 2, chap 47, p 1582.

2010 - 112 A patient complains of lack of erectile efficacy with 20 mg of tadalafil. He has used it six times and always takes it with dinner. The next step in treatment is: A. continue 20 mg of tadalafil. B. take on an empty stomach. C. increase the dose of tadalafil. D. change to vardenafil. E. change to intracorporal alprostadil.

E . The pharmacokinetic profile of the PDE5 inhibitors differs mainly in terms of the half life, with tadalafil having a significantly longer half life (17.5 hours) than vardenafil or sildenafil (4-6 hours). The other principle difference is in absorption with a concomitant fatty meal. Both vardenafil and sildenafil have decreased absorption with a high fat meal while the absorption of tadalafil is not affected by food consumption. Many studies show that at least four to six attempts may be needed to demonstrate that a patient will respond to PDE5 inhibitors. This patient has had an adequate trial of tadalafil and taking it on an empty stomach would not improve its efficacy. He has already been given the maximum FDA approved dose of tadalafil and increasing his dose will only increase the incidence of side effects. No level one evidence exists that switching PDE5 inhibitors will improve efficacy. Initiating treatment with intracorporal alprostadil would be a reasonable next step to efficaciously treat his erectile dysfunction. Carson C: Phosphodiesterase type 5 inhibitors: State of the therapeutic class. UROL CLIN N AM 2007;34:508-509.

2009 - 53 A 52-year-old man with depression has a low libido. Physical exam reveals obesity but is otherwise normal. Morning serum testosterone is 290 ng/dl (normal > 300 ng/dl) sex hormone binding globulin is 11 nmol/l (normal 10 - 70 nmol/l) albumin is 4.9 g/dl (normal 3.5 - 5.2 g/dl) prolactin is 9 ng/ml (normal < 19 ng/ml) calculated free testosterone is 2.85% and calculated bioavailable testosterone is 220 ng/dl (75.8%) The next step is: A. serum LH and FSH assay. B. morning urinary cortisol assay. C. cranial MRI scan. D. administer topical testosterone. E. psychiatric referral.

E . Serum testosterone circulates in three forms. Approximately 2% is free, 30% is tightly bound to sex hormone binding globulin (SHBG,) and the remainder (approximately 68%) is loosely bound to albumin and other serum proteins. Free and bioavailable testosterone may be accurately calculated by albumin and SHBG values. In this patient, while the total testosterone is slightly low at 290 ng/dl, free testosterone is well above 2% and bioavailable testosterone is well above 68% at 75.8%. Normal bioavailable testosterone concurrently existing with low total testosterone is commonly encountered in men with obesity. As an endocrine etiology is unlikely in this patient with depression and low libido, psychiatric referral is indicated. LH assay is not indicated as bioavailable testosterone is adequate, and FSH assay reveals seminiferous epithelial function which is not of interest in this case. In a patient with a normal physical examination other than obesity, Cushing's syndrome is unlikely, and morning urinary cortisol assay is not indicated. With prolactin in the normal range, a pituitary tumor is unlikely, and cranial MRI scan is not indicated. In a patient with depression, loss of libido and adequate bioavailable testosterone, psychiatric referral should be undertaken prior to testosterone therapy. Sokol RZ, Swerdloff RS: Endocrine evaluation, in Lipshultz LI, Howards SS (eds): INFERTILITY IN THE MALE, ed 3. St. Louis, Mosby Year-Book Inc, 1997, chap 11, p 211. Lue TF, Broderick GA: Evaluation of nonsurgical management of erectile dysfunction and premature ejaculation, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 22, p 767.

2011 - 88 The primary goal in the treatment of premature ejaculation is: A. intra-vaginal ejaculatory latency > 1 minute. B. intra-vaginal ejaculatory latency > 3 minutes. C. intra-vaginal ejaculatory latency > 5 minutes. D. improved self-perception of ejaculatory control. E. improved patient and partner satisfaction.

E . The AUA premature ejaculation (PE) guidelines suggest that patient and partner satisfaction is the main end-point in the treatment of PE. The patient and his partner (should one exist) can be reassured that PE is a common and treatable disorder. Information on the risks and benefits of all therapeutic options should be presented to the patient (and partner) so that an educated treatment choice may be made by the patient in consultation with the physician. Premature ejaculation is not a life-threatening condition; therefore, safety should be another significant consideration. Of note, none of the medical therapies currently employed in the management of PE have been approved by the Food and Drug Administration for this specific indication. Montague DK, Jarow J, Broderick GA, et al: Guideline on the pharmacologic management of premature ejaculation. PHARMACOLOGIC MANAGEMENT OF PREMATURE EJACULATION GUIDELINE. American Urological Association Education and Research, Inc, 2004. http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines.cfm?sub=pme

2010 - 70 During inflatable penile prosthesis surgery, the device is inspected for proper inflation and deflation after corporotomy closure. At maximal cylinder inflation, the glans flops ventrally over the distal portion of the cylinders. The next step is: A. complete procedure with cylinders deflated. B. complete procedure with cylinders inflated. C. crural plication. D. fix the glans to the tunica dorsally at the distal ends of the corporal bodies. E. reassess the corporal bodies for cylinder size.

E . The description suggests an impending supersonic transport (SST) deformity which is a ventral chordee of the glans whereby the distal aspects of the cylinders inadequately extend distally under the glans creating a floppy appearance. The floppy appearance mimics the drooped nose of the Concorde, a supersonic transport. A likely basis for the problem is inadequate dilatation and sizing of the corporal spaces. If this is identified during prosthesis placement, the corporotomies should be reopened and the corporal bodies inspected to be sure proximal perforation has not occurred. Redilation and remeasurement of corporal bodies are then performed, and the same cylinders can usually be reinserted adding rear-tip extenders to achieve appropriate length. A distal corporal plication (Ball procedure) is not generally required during initial prosthesis placement. The device should remain in the deflated position at the completion of surgery until the time of device activation and initiation of use to avoid the risks of an unexpanded cavity space for the reservoir (that is associated with autoinflation), penile pain and distal corporal perforation. Montague DK: Prosthetic surgery for erectile dysfunction, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 23, pp 788-801.

2011 - 79 A 66-year-old man, two years post-radical prostatectomy, seeks advice about therapy of severe urinary incontinence and complete erectile dysfunction. Both conditions are non-responsive to medical therapy. The next step is: A. wait one year before definitive treatment. B. artificial urinary sphincter first and a penile prosthesis at a later date. C. penile prosthesis first and an artificial urinary sphincter at a later date. D. penile prosthesis first and a male sling at a later date. E. synchronous insertion of an artificial urinary sphincter and penile prosthesis.

E . The ease of the transscrotal approach for penile prosthesis implantation and the proximity of the urethra has allowed the evolution of a new strategy for dual implantation of an artificial urinary sphincter (AUS) and inflatable penile prosthesis (IPP) at a single setting. Concerns regarding increased infection rates and poor outcomes have prevented widespread acceptance of this simultaneous implantation technique. A multi-institutional evaluation of dual prosthesis implantation was performed to determine the overall efficacy, safety and long-term success of this innovative approach. Only patients undergoing dual implantation via a single transscrotal technique were included for evaluation. A total of 22 men underwent AUS and IPP device implantation between 2000 and 2003 in a synchronous manner. Mean followup was 17 months. Complications were urethral erosion in two patients (9%) and reservoir migration in two (9%), of whom one underwent revision. Importantly no patient experienced a prosthetic infection postoperatively. The overall revision rate was 14%, due to urethral erosion of the AUS in two patients and reservoir migration in one. Initial intermediate followup in patients who underwent synchronous dual prosthetic implantation was favorable. The inherent advantage of a single anesthetic event and a single transscrotal incision should encourage widespread acceptance of this technique. Sling insertion and the IPP may also be done simultaneously. Kendirci M, Sanjeev Gupta S, Shaw K, et al: Synchronous prosthetic implantation through a transscrotal incision: An outcome analysis. J UROL 2006;175:2218-2222.

2010 - 16 A 65-year-old man with insulin-dependent diabetes chooses a vacuum constriction device for treatment of erectile dysfunction. After attempted use he reports insufficient rigidity for penetration. The most likely explanation is: A. inadequate cavernosal arterial flow. B. fibrosis of the corpora spongiosum. C. corporal muscle dysfunction. D. diabetic neuropathy. E. improper device use.

E . The vacuum constriction device should create penile rigidity sufficient for vaginal penetration in almost all impotent men who are treated. Adequate rigidity should be obtained, as long as the patient does not have significant intracorporal scarring from severe Peyronie's disease or a prior infected penile implant. Vacuum constriction devices even work in patients who have had a penile prosthesis removed. Often patients who are not given adequate instruction initially will not apply sufficient vacuum to fully distend the penis or do not use a small enough compressive ring at the base to achieve adequate rigidity. In these cases, instruction and reassurance is usually all that is necessary. Lue TF: Physiology of penile erection and pathophysiology of erectile dysfunction, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 21, p 783.

2012 - 97 A 67-year-old man develops erythema and mild tenderness in the scrotum six weeks following placement of a three-piece inflatable penile prosthesis. He has no tenderness or erythema in the penile shaft or suprapubic area. The best treatment is: A. oral antibiotic therapy for six weeks. B. I.V. antibiotic therapy for six weeks. C. removal and replacement of the scrotal pump. D. removal of the entire device and replacement in six months. E. removal of the device with washout and immediate replacement.

E . This patient clearly demonstrates an early prosthetic infection manifested around the scrotal pump. Treatment of a prosthetic infection with antibiotics usually results in clinical improvement but is almost never the definitive treatment and the infection will recur. This is due to microorganisms within a biofilm that is adherent to the device and the inability to sterilize the device or the biofilm once these organisms are present. When a prosthetic infection is present, all components of the prosthesis should be removed. If they are removed a new device should be replaced as soon as is feasible (within six to eight weeks) to decrease the amount of fibrosis and significant penile shortening which will occur. Mulcahy introduced the concept of immediate prosthesis salvage for infection which has been able to salvage as many as 85% of these patients and prevent penile shortening. His protocol involves removal of all prosthetic components followed by irrigation with seven antibacterial solutions. Others have reported on using different numbers and types of solutions. Mechanical irrigation and removal of the biofilm appears to be the key principle of this technique. A new device is implanted immediately after irrigation, and the patient is prescribed antibiotics. When salvage procedures are successful, they maintain penile size and correct the problem with only one operation. Montague DK: Prosthetic surgery for erectile dysfunction, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 23, p 801.

2011 - 18 A 25-year-old man has inadequate erections since sustaining a pelvic fracture in a MVC two years ago. After a successful urethral stricture repair, he denies any difficulty with orgasm and ejaculation. Intracavernosal injection of 15 ug of prostaglandin E1 produces a soft erection. The next step is: A. infusion cavernosography. B. pelvic/pudendal arteriography. C. infusion cavernosometry. D. intracavernosal injection of 30 ug of prostaglandin E1. E. color Doppler study of penile arteries.

E . This patient most likely has either an arterial or a neurologic injury to explain his erectile difficulty. A neurologic lesion is less likely because of his failure to respond with an erection to a reasonable dose of prostaglandin E1. Patients with neurogenic injuries frequently respond to very low doses of intracavernosal agents. The major clinical question which needs to be answered is whether or not this patient has an arterial injury. Infusion cavernosography and infusion cavernosometry are studies which demonstrate the extent and site of corporovenous leakage. Fifteen ug of prostaglandin E1 is a reasonable dose of drug to administer and increasing the dose to 30 ug would likely not produce more information. The study of choice to determine the presence of arterial disease in this clinical situation is a color Doppler study of the penile arteries before and after the intracavernosal injection of vasoactive drugs. Only after arterial disease has been diagnosed and only when operative revascularization is under consideration should pelvic/pudendal arteriography be performed. Lue TF, Broderick GA: Evaluation of nonsurgical management of erectile dysfunction and premature ejaculation, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 22, pp 757-759.

2013 - 145 A 35-year-old man with azoospermia and normal genetic testing desires a biological child. Testosterone is 275 ng/dl, LH is 28 IU/l and FSH is 15 IU/l. Both testes are 3 cm in length and soft. The next step is: A. clomiphene citrate. B. hCG. C. scrotal ultrasound. D. cranial MRI scan. E. microsurgical testicular sperm extraction.

E . With FSH greater than 7.6 IU/l and testis axis less than 4.6 cm, the probability of non-obstructive azoospermia is 89%. Neither clomiphene citrate nor hCG is effective in a patient with highly elevated LH, as clomiphene acts to increase LH secretion and hCG is an LH surrogate. Scrotal ultrasound would not reveal more than that identified on physical examination. As the pituitary is responding appropriately to low serum testosterone, MRI is not indicated. The only chance of a biological child for this patient with non-obstructive azoospermia would be testicular sperm extraction for intracytoplasmic sperm injection. Sabanegh E, Agarwal A: Male infertility, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 1, chap 21, p 634. Schoor RA, Elhanbly S, Niederberger CS, Ross LS: The role of testicular biopsy in the modern management of male infertility. J UROL 2002;167:197-200.